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I 


ABDOMINAL    TUMOURS 


DIAGNOSIS 


AND 


SUEGICAL    TREATMENT 


OF 


ABDOMINAL    TUMOURS 


By   sir   SPENCEE   WELLS,   Bart. 

LATE   PRESIDENT   OP   THE   ROYAL   COLLEGE   OF   SURGEONS   OF   ENGLAND 


PHILADELPHIA 

P.    BLAKISTON,     SON,     AND     GO. 

1012    WALNUT    STREET 

1885 


4  3  -D-65)^9- 


PEEFACE 


The  book  which  I  have  now  written  is  in  many  respects  a  new  work,  though 
it  may  be  called  a  fourth  edition  of  the  first  published  in  1865.  Twenty 
years  have  entirely  changed  the  boundaries  of  the  subject.  Before  1860, 
ovariotomy  sometimes  succeeded,  as  often  failed,  and  was  very  generally 
discredited.  My  first  book  was  a  record  of  cases,  showing  how  difficulties 
were  overcome,  how  principles  were  gradually  brought  into  view,  how  rules 
of  practice  were  established,  and  what  results  might  be  obtained.  It  silenced 
objections,  and  encouraged  others  to  follow  in  the  same  course.  My  second 
book,  in  1872,  was  no  longer  a  plea  for  ovariotomy.  An  experience  of  500 
cases,  which  then  seemed  large,  made  me  feel  that,  though  I  was  still  a 
learner,  there  was  something  I  could  usefully  teach,  and  had  no  right  to 
withhold.  According  to  the  views  then  held,  I  went  iato  the  diagnosis  of 
ovarian  disease  and  into  the  details  of  ovariotomy.  There  is  evidence  enough 
that  my  example  and  teaching  were  not  unfruitful.  Ten  years  more  brought 
into  the  field  many  co-labourers  who  tilled  the  ground  I  had  partially 
cleared,  and  no  one  is  more  ready  than  I  am  to  acknowledge  the  value  of 
what  they  have  done,  and  to  rejoice  over  the  relief  they  have  given  to  a 
multitude  of  sufferers.  My  own  experience  had  more  than  doubled,  some 
of  my  views  had  changed,  in  some  respects  my  practice  was  modified,  and  I 
had  information  acquired  from  others  to  add  to  my  own  observations.  The 
subject  had  expanded.  Uterine  pathology  and  surgery  had  been  grafted 
upon  that  of  the  ovary,  and  my  third  book,  in  1882,  included  both.  Since 
that  time  the  'domain  of  abdominal  surgery'  has  not  only  spread  over  every 
abdominal  organ,  but  has  been  taken  possession  of  with  equal  zeal  by  the 
profession  throughout  the  civilised  world.  The  proof  of  this,  so  far  as  I  am 
concerned,  is  that  in  less  than  two  years  a  new  edition  of  my  last  book  is 
called  for.  I  have  adopted  a  new  form,  and  issue  it  at  a  price  which  puts 
the  information  it  contains  at  the  command  of  every  student.  Suppression 
and  condensation  have  enabled  me  to  bring  this  work  into  smaller  compass, 
and  have  also  enabled  me  to  make  considerable  additions  on  various  conditions 
which  call  for  the  performance  of  abdominal  section.  Details  which  were 
interesting  when  novelties  have  been  omitted.  My  time  has  been  too  fully 
taken  up  as  a  practical  surgeon  for  me  to  do  much  as  a  pathological  explorer. 
Eesearches  in  ovarian  pathology  have  been  too  limited  and  the  facts  collected 


Yl  PREFACE 

too  fe'w,  for  any  but  the  most  empirical  conclusions.  Tliere  are  laws  of 
disorder,  degeneration,  and  decay  as  well  as  laws  of  evolution,  development, 
and  function.  It  must  be  by  reasoning  on  the  facts  gathered  together,  by 
a  survey  of  all  the  coiTesponding  structures  and  diseases  through  the  whole 
series  of  organic  life,  that  we  shall  arrive  at  some  solution  of  the  problems 
of  ovarian  pathology.  Fortunate  it  is  for  humanity  that  the  art  of  relief  is 
somewhat  independent  of  scientific  generalisations.  Some  observers  main- 
tain that  ovarian  disease  is  an  affair  of  race — that  it  is  much  more  common 
in  Great  Britain  and  Germany  than  in  France  or  Spain.  If  it  be  so,  there 
is  a  special  call  upon  British  pathologists  to  do  as  much  in  the  way  of  study- 
ing causes  and  prevention  as  British  surgeons  have  done  by  way  of  cure  ; 
and  I  would  repeat  the  hope  which  I  expressed  in  1882,  in  the  preface  to 
the  third  edition,  '  that  the  pathological  industry  of  those  who  are  not 
ovei-whelmed  with  the  routine  of  mere  clinical  labour  will  bring  us  to  such 
an  understanding  of  the  origin,  causes,  and  nature  of  these  diseases  as  will 
give  us  the  means  of  arresting  their  development  and  progress,  and  will 
shield  us  from  the  reproach  of  being  able  only  to  offer  the  ultimate 
resource  of  relief  by  excision.' 

In  condensing  I  have  expunged  nothing  of  practical  value,  and  perhaps 
have  made  some  points  more  clear  than  they  were.  The  additions  are  large, 
and  naturally  arise  out  of  the  gl•o^vth  of  the  subject.  Never  a  mere  bvario- 
tomist,  I  have  followed,  and  sometimes  led.  the  advance  of  abdominal  surgery, 
and  this  new  edition  or  new  book  now  includes  the  operative  treatment  of 
various  kinds  of  tumours — splenic,  renal,  hepatic,  and  others — hardly  noticed 
in  my  earlier  books. 

But  there  is  one  fact  which  stands  out  with  ominous  significance  in  all 
these  records.  Whatever  may  be  our  diagnostic  accuracy  and  our  operative 
skill,  our  success  in  the  treatment  of  these  diseases  is  fatally  restricted  by 
the  influence  of  septicsemia.  We  have  already  reached  as  great  an  amount 
of  success  in  the  results  of  ovariotomy  as  can  reasonably  be  hoped  for,  and 
shall  in  like  manner  approach  such  success  in  the  results  of  the  extii-pation 
of  other  organs.  But  until  we  find  some  more  certain  protection  for  our 
patients  against  the  ravages  of  septic£Emia  than  any  antiseptic  precautions 
hitherto  taken  secure,  abdominal  surgery,  though  not  without  just  claim  to 
the  credit  of  liaving  done  good  ser\"ice  to  humanity,  must  still  be  looked 
upon  as  a  branch  of  our  science  and  art  which,  still  imperfect,  calls  for 
continued  search  for  truth,  and  for  constant  efforts  to  improve  methods  of 
practice,  from  every  surgical  student. 

Uppeb  (Jrosvexoe  Street,  London  : 
April  ]  885. 


CONTENTS 


PAET  I 

OVAJRIA^^  AXB  ALLIED   TUJIOmS 

CIIAPTETl  PACE 

I,  Classification  of  Otariax  axd  Allied  Tc:.iocrs — Diagxosis  of  Adhesions — The 

Pedicle — Kotation  of  the  Pedicle      .........       1 

II.  Differentiae  Diagnosis  of  Otabian  Tumours 10 

III.  Palliative  and  Minor  Scegicae  Treatment  of  Otarian  Toiours        .         .         .37 

IV.  The  Eise  and  Progress  of  Otaeiotomt .     46 

V.  The  Conditions  affecting  the  Operation  of  Otariotomy 67 

YI.  Preparation  of  a  Patient  for  Ovariotomy  ;  Duties  of  the  Xurse  ;  Desceiftion 

OF  necessary  Instruments        ...........     73 

VII.  The  Operation  of  Ovariotomy — Division  of  the  AsDoanNAL  "W'ael  ;  Situation 
and  Length  of  the  Incision  ;  Separation  of  the  Cyst  ;  Emptying  and  Ee- 
moval;  Treatment  of  the  Pedicle;  Sponging  of  the  Peeitontxm;  Closure 
of  the  "Wound  ;  Dressing  and  Bandage      ........     80 

VIII.  Accidents  during  Ovariotomy 97 

IX.  On  the  Eemoval  of  both  Ovaries  at  ont:  Operation  .         .         .  .         .100 

X.  On  Ovaeiotojiy  peefoemed  Twice  on  the  same  Patient  102 

XL  On  the  Treatment  of  Patients  after  Ovariotomy        .         .         .         .         .         .106 

XII.  0vaeiot03it  during  Pregnancy .         .         .     .  115 

XIII.  On  Incomplete  Ovariotomy  and  Exploratory  Incisions 121 

XIV.  Oophorectomy — or  Battey's  Opeeation 125 

XV.  Eesults  of  Ovariotomy.     Subsequent  History  of  Patients  who  Eecover  .         .  130 


PART   II 
UTERIXE  AXD    OTHER  AEROJIIXAL    TUMOURS 

I.  Uterine  Tumours 134 

II.  On  Partial  Amputation  and  Complete  Excision  of  the  L^terus  .        .         .171 

III.  Extirpation  of  the  Spleen        . 182 

IV.  Operative    Suegery    of   the   Ividntey — Xepheoraphy  ;    Tapping   and   Drainage  ; 

Nepheotomy;  Xepheolithotomy  ;  Nephrectomy  .         .         .         .         .         .         .190 

V.  Liver  and  Gall-Bladder — Abscess   anto   Hydatids  ;    Distent)ed    Gall-Bladder  ; 

Gall-Stones  ;   Cholecystotomy  and  Ckouecystectomy     ......  201 

VI.  3Iesenteeic,  Omental  and  Pancreatic  Cysts — Undescended  Testicle  .         .         .  204 
VII.  The  Stomach  and   Intestint:s — Gastrostomy   ant)    Gastrotomy  ;    Dilatation   of 
Pyloric   and   Cardiac    Orifices  ;   Pyloeectomy  ;    Obstructed   Intestine  ;   En- 
terotomy  and  Colotomy  ;  Artificial  Ants  :  Eesection  of  Intestine  ;  Operative 
Treatment  of  Peritonitis 207 


DIAGNOSIS  AND  SUKQICAL  TREATMENT 


OF 


ABDOMINAL    TUMOURS 


PART   I. 

OVAR/AN  AND  ALLIED  TUMOURS— THE fB   DIAGNOSIS 
AND   SURGICAL.  TREATMENT 


CHAPTER   I 


CLASSIFICATION    OF    OVAPJAX    AND    ALLIED    TUMOURS — THEIR    DIAGNOSIS— DIAGNOSIS    OF 
ADHESIONS — THE    PEDICLE ROTATION     OF    THE    PEDICLE 


Abdominal  and  pelvic  tumours  con- 
nected with  the  female  organs  of  gene- 
ration may  be  classified  in  the  following 
manner : 

OVARIAN    TUMOURS 

Simple  and  multilocular  cysts — of 
follicular  origin. 

Proliferous  cysts — of  epithelial  origin. 

Sarcomatous  tumours — of  connective- 
tissue  origin. 

Fibrous  tumours — of  fibre-cell  origin. 

Hypertrophy — excess  of  growth  of 
some  or  all  of  the  tissues. 

Malignant  tumours — -degeneration  of 
one  or  all  of  the  tissues. 

EXTRA-OVARIAN    TUMOURS 

Cysts  of  parovarium — of  epithelial  or 
tubular  origin. 

Cysts  of  broad  ligament — origin,  con- 
nective-tissue cells  or  ova. 

Cysts  of  Fallopian  tubes — origin,  ova, 
epithelium  tissues  ;  by  occlusion. 

Cysts  of  subperitoneal  tissues — con- 
nective-tissue cells. 

Cysts  developed  from  aberrant  ova — 
of  ovarian  follicular  origin. 

The  ovary  is  no  exception  to  the  uni- 
versal law  of  development.  It  begins 
Avith  a  cell.  The  combined  progeny  of 
the   primitive    cell    is    as    diverse,    and 


subject  to  as  many  deviations  from  natural 
growth  and  action,  as  any  other  cell  struc- 
ture. Each  series  of  cells  may  go  wrong 
separately  ;  a  few  series  of  cells  may  go 
wrong  together  and  entrain  the  rest,  or 
the  whole  may  go  wrong  at  the  same 
time.  It  is  easy  to  understand  how,  by 
continued  development,  from  a  diseased 
reproductive  cell  we  may  have  a  simple 
or  multilocular  cyst ;  from  endothelium,  a 
papilloma ;  from  a  group  of  connective 
tissue  cells,  a  sarcoma ;  from  fibre  cells, 
a  fibroma ;  and  with  partial  or  general 
degeneration  of  the  tissues,  some  form  of 
malignant  tumour.  In  the  same  way,  we 
ti'ace  the  origin  of  extra-ovarian  cysts 
and  tumours  to  the  histological  elements 
of  the  tissues  in  which  they  appear,  the 
structural  characteristics  depending  upon 
the  nature  of  the  cell  point  of  departure. 

MODES    OF    EXAMINATION    OF    THE  OVARIES 

Absence  of  the  ovaries,  from  their 
imperfect  development  or  atrophy,  may 
occasionally  be  inferred  from  some 
physical  peculiarities  or  pliysiological 
aberrations ;  and  the  presence  of  an 
accessory  ovary,  now  and  then  observed, 
may  probably  account  for  the  recurrence 
of  menstruation  in  spite  of  disease,  or  after 
the  removal  of  two  by  ovariotomy. 

The  manipulation  in  the  examination 


OVARIAN   AND   ALLIED   TUMOURS 


of  the  congenital  or  accidental  displace- 
ments of  the  ovaries  requires  skill  and 
care.  The  ovaries  may  generally  he  felt 
in  their  normal  position  on  either  side  of 
the  uterus,  a  little  below  the  brim  of  the 
pelvis,  between  one  finger  passed  upwards 
in  the  vagina  and  another  pressed  down- 
wards from  the  abdominal  wall.  It  is 
only  in  cases  of  firm  vagina,  or  very  tense 
or  thick  abdominal  wall,  that  the  ovaries 
cannot  be  made  out. 

In  order  that  this  examination  may  be 
done  effectually,  the  patient  should  be 
made  to  lie  on  her  back,  with  the  shoul- 
ders and  knees  raised  so  as  to  relax  the 
belly,  and  both  bladder  and  rectum  must 
be  empty.  It  is  only  by  combined  in- 
ternal and  external  examinations  that  a 
normal  ovary,  or  one  only  slightly  enlarged, 
can  be  detected.  External  examination 
alone  is  fruitless.  .  By  vaginal  examina- 
tion alone  a  resisting  body  may  perhaps 
be  felt  through  the  upper  part  of  the 
vault  of  the  vagina :  its  mobility  may  be 
recognised,  but  nothing  more.  Some- 
times the  ovaries  are  so  easily  displaced 
that  t'ley  elude  internal  examination 
alone.  Yet  two  fingers  brought  together, 
one  from  without  and  one  from  within, 
may  fix  and  feel  the  ovary  between  them. 
It  is  well  first  to  find  the  fundus  uteri  and 
to  steady  it  by  one  or  two  fingers,  and 
then  by  the  combined  examination  an 
ovary  is  found  near  the  uterus,  on  one 
side  of  it.  The  finger  can  be  passed 
around  it,  and  it  may  be  pushed  from 
before  backwards,  and  less  easily  towards 
and  away  from  the  side  of  the  uterus. 
It  has  a  firm  elastic  feel,  glides  easily 
under  the  fingers,  and  unevenness  of  the 
surface  may  often  be  detected. 

A  small  hard  mass  of  fteces  in  the 
bowel,  a  swollen  pelvic  gland,  a  cyst  in 
the  broad  ligament,  a  dilatation  of  the 
Fallopian  tube,  or  a  small  pedunculate 
outgrowth  from  the  titerus  might  give 
a  similar  impression  to  the  examining 
fingers,  but  after  some  practice  this  will 
not  be  mistaken  for  the  characteristic 
feel  of  the  ovar3\ 

The  right  ovary  is  most  easily  reached 
l)y  one  or  two  fingers  of  the  right  liand 
in  the  vagina,  the  left  hand  being  on  the 
abdomen  ;  the  left  ovary  by  the  left  hand 
being  used  for  the  vagina,  and  the  right 
rfbr  the  outside. 

Examination  by  the  rectum  is  in  some 
cases  more,  in  others  less,  useful  than  by 
the  viigina.     Occasionally,  when  the  rec- 


tum is  large  and  the  vagina  tense,  one  or 
both  ovaries  may  be  distinctly  felt  by  the 
rectum  and  not  by  the  vagina.  In  some 
cases,  when  the  ovaries  can  be  readily 
felt  by  the  vagina  they  cannot  be  touched 
by  the  rectum.  Even  in  the  case  where 
the  ovary  is  abnormally  situated  in 
Douglas's  space  it  may  be  palpable 
through  the  posterior  wall  of  the  vagina, 
and  the  fingers  of  the  hand  compressing 
the  abdomen  meet  a  finger  in  the  vagina 
much  more  readily  than  one  in  the  rec- 
tum. Examination  both  by  rectum  and. 
vagina  is  necessary  when  an  ovary,  not 
enlarged,  is  supposed  to  be  in  Douglas's 
space,  for  Schultze  has  known  a  gland 
behind  the  rectum  to  be  felt  through  the 
vagina  and  mistaken  for  an  ovary. 

It  must  be  remembered  in  judging  of 
the  size  of  an  ovary,  that  if  small,  and 
felt  through  a  thick  abdominal  wall,  it 
will  appear  to  be  larger  than  it  is,  and 
that  ovaries  of  the  same  size  felt  through 
walls  of  different  thickness  may  appear  to 
be  of  different  sizes.  A  little  practice 
will  be  sufficient  to  teach  what  allowance 
should  be  made  in  face  of  this  source  of 
possible  error. 

A  healthy  ovary  is  generally  insensible 
to  moderate  pressure.  But  touch  may 
give  pain  when  there  is  no  reason  to  sus- 
pect inflammation  or  any  other  departure 
from  a  state  of  health.  The  diagnosis 
can  only  be  made  out  when  the  swollen 
and  painful  ovary  is  felt  as  a  circum- 
scribed  lump. 

Schultze  says  he  has  observed  that 
the  displacement  of  the  ovary  during  in- 
flammation may  rather  be  into  Douglas's 
space  than  to  the  front  of  the  uterus,  and 
that  on  regaining  its  usual  volume  and 
sensibility  it  has  returned  to  its  natural 
position.  In  other  cases  after  recovery  it 
remains  fixed  ;  and  once  an  ovary  which 
had  been  adherent  to  the  uterus  after  in- 
flammation was  months  before  it  became 
again  movable. 

The  displacements  of  the  ovary  recog- 
nised by  this  mode  of  double  examination 
are  all  witliin  tlie  limits  of  the  abdominal 
cavity  ;  but  the  whole  gland  will  some- 
times find  its  way  through  the  weak  points 
of  tlie  parietes,  and  we  have  to  deal  with 
it  as  a  form  of  hernia,  either  inguinal, 
crural,  ischiatic,  umbilical,  ventral,  or 
vaginal.  Pott's  case  was  one  of  simple 
hernia  and  abscission ;  but  an  ovarian 
cyst  has  formed  outside  the  inguinal  ring, 
and  been  the  subject  of  an  extra-mural 


DIAGJ^OSIS 


ovariotomy  by  a  Spanish  surgeon.  An 
instance  of  this  kind  has  not  come  under 
my  notice,  but  I  do  not  see  that  it  can 
offer  any  difficuhies  to  the  operator. 

DIAGNOSIS    OF    THE    DIFFERENT    KINDS    OF 
OVAKIAN   TUMOUnS    AND     THEIR    ADHESIONS 

Many  of  the  signs  and  symptoms  of 
the  tumours  classified  in  this  chapter  are 
common  to  the  whole  group.  Tliere  are 
degrees  of  hardness  and  mobility ;  there 
are  shades  of  force  and  sharpness  in  fluc- 
tuation ;  there  are  eccentricities  of  form 
and  variations  in  relative  position  which 
in  different  cases  alter  the  areas  of  reson- 
ance and  dulness.  But  the  physical  signs, 
though  often  sufficient  for  diagnosis,  are 
sometimes  far  from  conclusive  till  we  come 
to  test  the  contents.  With  thgm  Ave  ob- 
tain additional  evidence,  and  are  able  to 
declare  in  certain  cases  li-om  what  sort  of 
cyst  they  are  drawn.  The  symptoms  of 
the  tubercular  and  malignant  tumours  are 
a  set  apart. 

With  the  cystic  enlargements,  simple 
and  compound,  there  are  from  the  first 
progressive  uneasiness  running  on  to  dis- 
tress, pain  from  nerve  pressure  and  stretch- 
ing, irritation  from  local  congestion,  and 
other  effects  purely  arising  from  me- 
chanical causes.  But  as  the  tumour 
grows  bigger  and  encroaches  on  the 
various  organs,  functions  are  interfered 
with  and  suspended,  the  lines  of  innerva- 
tion are  cut  or  compressed,  circulation  and 
absorption  are  interrupted,  nutrition  is 
arrested,  and  the  victim  dies  atrophied  or 
suffocated.  The  evidence  from  mere  sym- 
ptoms is  all  along  more  circumstantial 
than  specific,  and  assists  rather  in  fore- 
casting the  end  than  in  identifying  any 
particular  kind  of  cyst. 

No  time  of  life  is  exempt  from  ovarian 
tumours.  They  are  found  in  infancy  as 
well  as  in  old  age,  though  it  is  seldom  that 
the  development  begins  late.  When  seen 
in  advanced  life  they  are  generally  ex- 
amples of  longevity  of  the  tumour  no  less 
than  of  the  person.  The  greater  part  of 
my  patients  have  come  to  me  between  the 
ages  of  25  and  55,  and  the  average  age 
on  my  list  of  1,000  cases  of  completed  ova- 
riotomy is  as  near  as  may  be  39.  This 
would  seem  to  show  that  the  condition  of 
the  generative  function  has  a  great  deal 
to  do  with  the  origin  of  the  disease.  What 
Boinet  says  about  childless  -women,  that 
'  sur  500  i'emmes  atteintcs  de  kys^tcs  de 


I'ovaire,  nous  en  avons  trouve  390  qui 
n'avaient  jamais  eu  d'enfants,'  points  either 
to  a  cause  or  a  consequence,  and  certainly 
to  some  connection  between  the  two 
facts. 

It  has  been  said  that  the  ovary  of  tlie 
right  side  is  more  frequently  affected  than 
the  left.  This  statement  is  rather  one 
of  impression  than  of  assurance.  Both 
ovaries  are  often  found  diseased  at  the 
same  time  in  different  degrees.  With  tliis 
evidence  of  sequence,  and  with  our  know- 
ledge of  the  sympathetic  morbid  action 
between  twin  organs,  no  question  can  be 
made  as  to  the  rule  of  practice,  as  accepted 
in  ophthalmic  surgery,  to  save  one  by 
cutting  out  the  other;  while  it  may  be  as 
wrong  to  cut  out  a  sound  ovary  as  a 
healthy  eye. 

A  long  duration  of  the  disease  is  ex- 
ceptional. Race  and  type  yield  equallv 
to  the  same  etiologic  influences.  M'Dowell 
soon  fell  upon  cases  among  negresses  as 
well  as  whites.  My  list  is  multicolor 
and  cosmopolitan,  and,  if  reports  may  be 
trusted,  ovariotomists  are  never  anywhere 
in  want  of  subjects. 

The  discovery  of  a  tumour  in  the 
abdomen  is  generally  made  by  the  patient 
herself.  The  question,  What  is  it  ?  is  one 
for  the  surgeon.  Having  satisfied  himself 
that  he  has  an  ovarian  tumour  to  deal 
with,  and  putting  aside  the  tuberculous 
and  cancerous  degenerations  which  are 
indicated  by  the  general  conditions,  to 
him  the  points  of  primary  importance  are 
its  seat,  solidity,  and  relative  freedom. 
He  has  to  make  out,  if  possible,  the  basic 
origin  of  this  tumour,  and  what  sort  of 
pedicle  it  has,  on  which  side  it  is  attached, 
and  whether  it  be  single  or  double.  It  is 
possible  that  there  may  be  a  cyst  of  both 
ovaries.  This  I  saw  for  the  first  time  in 
a  young  lady  whom  I  attended  with  Dr. 
Priestley.  There  was  a  distinct  sulcus 
between  the  two  cysts  near  the  median  line, 
and  it  became  a  question  whether  this 
Avas  owing  to  disease  on  both  sides  or  to 
the  peculiar  shape  of  a  cyst  on  one  side. 
It  Avas  supposed  that  the  latter  opinion 
was  more  probably  true,  because  the 
catamenia  Avere  regular  ;  but  at  the  opera- 
tion tAvo  free  simple  ovarian  cysts  Avere 
removed  Avithont  difficulty.  In  one  case 
the  appearance  leading  to  suspicion  of 
both  ovaries  being  diseased,  depended  on 
a  deep  sulcus  in  the  cyst  caused  bv  the 
rotation  of  ihe  tumour  and  the  ]iull  on 
the  Fallopii  n  tube.      W  the   resonance   of 

B   2 


OVARIAN    AND  ALLIED  TUMOURS 


intestine  can  be  traced  low  down  in  front 
between  two  cysts,  the  probability  of 
disease  on  both  sides  is  strong. 

The  next  questions  are,  wliether  the 
tumour  is  cystic  or  solid,  or  whether  it  is 
free  or  adherent ;  and  if  adherent,  whether 
the  adhesions  are  of  such  a  character  that 
they  may  be  separated  without  risk,  or 
so  extensive  and  intimate  that  separation 
•would  be  almost  certainly  fatal.  On  their 
solution  depends  the  decision  whether 
tapping  should  or  should  not  be  recom- 
mended ;  whether  drainage  should  be 
tried,  or  whether  ovariotomy  would  be 
the  best  practice  ;  whether  this  operation 
could  be  done  with  more  or  less  than  the 
average  chances  of  a  good  result ;  or 
whether  the  difficulties  would  be  so  great 
that  it  should  not  be  attempted,  even  if 
the  patient  were  herself  anxious  thereby 
to  escape  from  her  sufferings  whatever  the 
risk  might  be. 

Solid  tumours  of  the  ovary  are  ex- 
cessively rare.  In  two  of  the  cases  which 
I  have  seen,  the  tumours  were  surrounded 
by  fluid  in  the  peritoneal  cavity,  and 
it  was  only  after  removal  of  this  fluid 
that  the  size  and  consistence  of  the  body 
could  be  made  out.  Solid  portions  of 
large  tumours  which  fluctuate  in  other 
parts  are  common  enough,  but  general 
hardness  and  irregularity  of  form,  with 
nodular  masses  cartilaginous  or  bony  to 
the  touch,  almost  indicate  the  dermoid 
character  of  the  growth,  especially  in  a 
fair  and  young  patient. 

When  by  internal  and  external  exa- 
minations the  outline  of  the  tumour  can 
be  traced  smooth  and  elastic  over  its 
whole  extent,  when  the  wave  of  fluctuation 
is  etjually  perceptible  in  all  directions  and 
limited  by  the  line  ofdulness  on  percussion, 
and  the  want  of  resonanc?  is  circumscribed, 
the  inference  is  pretty  clear  not  only  that 
the  tumour  is  cystic,  but  that  it  is  prac- 
tically unilocular. 

This  simple  cyst,  however,  may  be 
either  ovarian  or  extra-ovarian.  If  in  a 
young  person  it  is  either  flaccid  and  of 
long  duration,  or  excessively  tense  and  of 
recent  formation,  the  inferi^nce  is  almost 
equally  clear  that  the  cyst  is  extra-ovarian 
and  the  contents  limpid.  x\s  this  kind  of 
cyst  especially  may  be  not  only  tempo- 
rarily emptied,  V)ut  emptied  with  some  pro- 
bability tliat  the  fluid  will  not  collect  again, 
it  is  interesting  to  ascertain  if  pf)ssible 
whether  it  is  really  single,  or  whether  there 
may  be  one  large  cyst  with  smaller  ones 


concealed.  Two  conditions  may  be  ac- 
cepted as  proof  that  an  extra-ovarian  cyst 
is  simple :  first,  that  it  has  lasted  for 
years  with  little  damage  to  the  health;  or 
second  1}',  that  it  has  formed  with  such 
rapidity  as  to  be  mistaken  for  ascites.  In 
the  first  of  these  two  conditions  the  cyst 
is  generally  flaccid,  and  there  is  little  or 
no  suffering  beyond  the  inconvenience 
arising  from  its  bulk.  In  the  second,  the 
cyst  is  tense,  and  there  is  the  suffering 
which  accompanies  undue  and  sudden 
abdominal  distension.  Both  are  likely  ta 
be  mistaken  for  ascites,  but  may  be  dis- 
tinguished by  the  signs  of  the  inclosure  of 
the  fluid  in  a  cyst,  enumerated  in  the  next! 
chapter. 

With  these  simple  cysts,  whether  of 
the  ovary  or  not,  the  health  is  fur  some 
time  but  little  affected.  The  first  appear- 
ance is  in  much  the  same  spot,  the  advance 
is  similar,  the  form  of  the  abdomen  and 
the  efiect  of  change  of  position  are  not 
different.  The  fluctuation  in  both  is 
limited,  but  to  the  touch  the  shock  is  not 
the  same.  It  is  as  distinct  in  the  one  as 
in  the  other,  but  from  the  character  of  the 
fluid  and  the  thinness  of  the  walls  in  the 
broad-ligament  cysts,  the  wave  impression 
under  percussion  in  them  is  more  defined. 
Scarcely  a  trace  of  these  tumours  can  be 
felt  after  tapping,  so  completely  do  the 
walls  collapse.  The  fluid  itself,  in  con- 
trast with  that  from  a  true  ovarian  cyst, 
is  thin,  clear,  odourless,  and  any  coagulum 
formed  by  boiling  isredissolved  by  boiling 
acetic  acid.  On  this  test  the  practitioner 
may  mostly  rely  with  safety,  and  found  a 
reasonable  hope  that  further  proceedings 
will  t^e  unnecessary. 

There  are  many  cysts  which,  although 
practically  unilocular,  have  on  some  part 
of  the  Avail  o£  the  mother  cyst,  most  com- 
monly near  the  base,  a  group  or  groups  of 
secondary  C3's1s,  Avhich  negative  the  sup- 
position that  the  tumour  is  extra-ovarian^ 
and  the  contents  instead  of  being  limpid 
will  in  many  instances  prove  to  be  viscid. 
Multilocular  cysts  are  sometimes  as  uni- 
form in  outline  as  simple  cysts,  but  as  a 
rule  their  surface  is  more  or  less  irregular 
from  the  unequal  development  of  their 
component  parts;  and  the  projection  of 
the  different  compartments  can  be  both 
felt  and  seen.  Thiese  projections  vary  in 
hardness,  and  when  the  resistance  of  the 
C3'st  wall  to  pressure  i^!  considerable,  wdien 
the  flucttiation  is  limited  by  the  divisions 
between  the  cavities,  and  its  wave  is  sloAV 


DIAGNOSIS   OF  ADHESIONS 


and  d<iul;Lfu!,  the  proLaLility  is  that  the 
cyst  wall  id  thick  and  the  contents  colloid. 
A  septum  must  be  very  thin  which  does 
not  intercept  the  wave  of  fluctuation,  but 
•in  some  cases  of  colloid  tumours,  where 
the  septa  are  imperfect,  the  impulse  of 
the  percussed  fluid  is  almost  as  distinct 
and  instantaneous  as  in  a  true  unilocular 
cyst. 

Boinet  believes  that  the  coloiu-  and 
•consistence  of  the  contents  of  multilocular 
cysts  may  be  predicted  before  tapping. 
The  progress  of  the  disease,  the  signs  of 
inflammation  more  or  lei-s  acute  and  re- 
peated, and  the  state  of  the  health,  Avill  be 
sufficient  to  indicate  if  the  contents  are 
serous  or  purulent,  and  what  their  colour 
may  probably  be.  When  abdominal  pains 
have  been  frequent,  and  the  abdomen  is 
tender  on  pressure,  it  is  probable  that, 
Avhether  the  cyst  is  iinilocular  or  multilo- 
bular, the  contents  will  be  sero-sanguino- 
lent.  When  the  temperature  ranges  from 
100°  or  101°  in  the  'morning  to  103°  or 
104°  at  night,  and  emaciation  is  pro- 
gressive, appetite  lost,  thirst  troublesome, 
sleep  disturbed,  nausea  or  vomiting  dis- 
tressing, and  the  abdomen  tender  on 
pressure,with  hurried  pulse  and  respiration, 
it  is  probable  that  one  or  more  of  the  cysts 
may  contain  pus ;  and  that,  when  these 
symptoms  are  present  in  an  extreme  de- 
gree, or  have  lasted  for  a  considerable 
period,  the  pus  has  become  fetid.  Blood 
may  be  found  in  one  or  more  of  the  cysts, 
either  as  an  immediate  result  of  twisting 
of  the  pedicle,  or  as  a  more  slow  and 
gradual  oozing  from  degenerative  changes. 

When  any  considerable  amount  of 
blood  has  been  poured  into  the  cavity  of 
an  ovarian  cyst,  all  the  well-known  signs 
■of  internal  lja?morrhage  are  observed.  I 
have  twice  seen  sudden  death  occur  in 
this  way.  In  one  case  five  pounds  of 
blood  and  clot  were  removed  from  the  cyst 
into  which  they  had  been  suddenly  poured 
from  a  large  vein.  In  the  second  case  the 
blood  passed  into  the  peritoneal  cavity. 
Another  patient  died,  but  not  immediately, 
of  bleeding  thiough  the  Fallopian  tube 
and  uterus  from  a  large  cyst  of  the  left 
ovary. 

ADHESIONS 

In  the  early  days  of  ovariotomy  great 
pains  were  taken  to  ascertain  whether  a 
tumour  was  free  or  adherent,  and  if  ex- 
tensive adhesions  to  the  abdominal  wall 
were  believed  to   exist,  ovariotomy    was 


considered  to  be  improper  or  impracti- 
cahde.  Mr.  Walne,  in  1S43,  began  his 
operations  with  a  small  incision  just  large 
enough  to  enable  him  to  ascertain  with 
his  finger  whether  the  cyst  were  free  or 
not.  Dr.  Frederick  Bird  published  a  great 
number  of  cases  in  Avhich  he  made  an 
exploratory  incision,  and  abandoned  the 
operation  as  soon  as  he  found  that  the 
adhesions  were  intimate.  He  was  so 
anxious  to  ascertain  the  presence  or  ab- 
sence of  adhesions  that,  even  before  making 
an  exploratory  incision,  he  used  to  insert 
needles  through  different  parts  of  the 
abdominal  walls  into  the  cyst,  believing 
that  by  Avatching  the  movements  of  these 
needles,  as  the  patient  inspired  and  expired, 
he  could  make  out  whether  the  cyst  shifted 
its  place  beneath  the  abdominal  wall  or  not. 
Others  marked  thedeviationsof  thecannula 
after  tapping,  with  the  same  intention  and 
belief,  only  to  find  that  all  these  signs  were 
fallacious. 

Before  I  had  operated  on  any  con- 
siderable number  of  cases,  I  bcgiin  to  doubt 
whether  adhesions  seriously  affected  the 
result  of  the  operation,  and  on  analysing 
the  first  500  cases,  arrived  at  certain  con- 
clusions, to  be  found  in  the  fifth  chapter. 
The  experience  of  the  second  500,  and 
of  my  first  1,000,  as  a  whole,  afterwards 
modified  these  conclusions,  and  proves 
that  it  is  a  matter  of  some  interest  to  know 
what  are  the  signs  by  which  a  free  or  an 
adherent  cyst  may  be  recognised.  To  make 
^this  examination  the  patient  should  be 
placed  in  a  good  light,  lying  on  her  back, 
with  the  shoulders  and  knees  somewhat 
raised,  and  the  whole  abdomen  uncovered. 
By  watching  the  abdominal  movements 
during  deep  inspiration  and  full  expiration, 
a  free  ovarian  cyst  may  be  seen,  providing 
the  abdominal  Avail  is  not  too  thick,  moving 
upwards  and  downwardsAvith  every  breath. 
Irregular  elevations  and  depressions  on  the 
surface  of  the  cyst  make  its  free  mobility 
perfectly  manifest  and  indubitable;  but 
Avhen  the  surface  is  uniform  it  is  only  the 
upper  border  of  the  cyst  Avhich  can  be  seen 
to  move,  and  to  avoid  dece[.tion  it  may 
be  riecessary  to  ascertain  by  percussion 
how  high  the  outline  extends  above  the 
umbilicus ;  because  the  transverse  colon, 
following  the  respiratory  movements,  may 
be  easily  mistaken  for  a  moving  cyst.  A 
thick  abdominal  Avail  may  obscure  the 
movements  of  the  cyst  during  inspiration 
and  expiration,  but  it  is  quite  easy  to 
foUoAV  them  by  the  varying  position  of  the 


6 


OVARIAN  AND  ALLIED  TUMOURS 


dull  sound  of  the  cyst  and  the  clear  sound 
of  the  colon  under  percussion. 

The  dull  sound  at  the  upper  boundary 
of  the  cyst  will  often  descend  from  one  to 
two  inches  during  inspiration,  and  rise 
during  expiration,  just  as  the  cyst  is  seen 
to  move  in  patients  where  the  abdominal 
wall  is  thin.  With  clos^e  adhesions  to  the 
abdominal  wall  no  such  ireedom  of  motion 
can  be  observed,  nor  is  it  possible.  The 
cyst  and  the  abdominal  wall  nuist  move 
together  unless  the  adhesions  arc  loose.  I 
have  three  or  four  times  seen  cases  where 
the  cyst  moved  freely  beneath  the  abdomi- 
nal Avail,  but  in  which  very  firm  adhesions 
had  to  be  separated,  these  adhesions  con- 
sisting of  flattened  cellular  bands  or  cords 
of  fully  an  inch  in  length.  My  belief 
is  that  such  bands  of  adhesion  have  been 
elongated  by  the  free  motion  of  the  cyst, 
before  the  lymph  forming  the  connection 
had  been  thoroughly  organised  or  hardened. 
Once  aware  of  this  t-ource  of  fallacy,  it  is 
easy  to  check  it  by  placing  the  hands  Hatly 
on  the  abdomen  while  the  patient  breathes, 
when  any  long  bands  of  adhesion  give  a 
sensation  of  grating  or  crackling  to  the 
liand,  Avhich  can  only  be  mistaken  for  the 
rubbing  of  recent  lymph,  or  for  the  pre- 
sence of  omentum  in  iront  of  the  cyst.  With 
this  sensation  of  crepitus,  friction  sounds 
are  always  audible,  and  the  concurrence 
Avas  formerly  supposed  to  be  an  evidence 
of  adhesion  by  lymph  recently  effused  upon 
the  peritoneal  surface  of  the  cyst,  or  upon 
the  peritoneum  in  apposition  with  the  cyst. 
But  this  is  an  error.  So  long  as  the  fric- 
tion can  be  felt  or  Jieard,  movement  must 
be  free.  As  soon  as  adhesion  takes  place 
friction  ceases,  and  can  only  be  felt  again 
if  the  lymph  which  forms  the  connecting 
medium  becomes  so  stretched  that  motion 
again  becomes  possible  between  the  cyst 
and  the  abdominal  wall.  It  is  common 
for  crepitus  to  be  present  for  a  time,  and 
to  disappear  without  any  adhesion,  the 
lymph  being  removed  and  the  surface  of 
the  peritoneum  again  rendered  smooth. 
The  crepitus  which  is  produced  by  the 
presence  of  omentum  between  the  cyst 
and  the  abdominal  wall  may  be  mistaken 
for  tliat  caused  by  recent  lympli  or  old 
stretched  adhesions,  but  it  is  not  impossible 
to  distinguish  them  with  tolerable  certainty. 
With  omentum  there  is  a  softer  and  more 
doughy  feel,  and  it  is  seldom  present  over 
any  paitof  a  cyst  not  near  some  intestine. 
This  is  easily  recognised  by  its  resonance  on 
percussion  and  its  gurgling  luider  pressiu-o, 


and  there  is  neither  the  tenderness    nor 

feverishness  which  accompany  the  i-ecent 
effusion  of  lymph. 

This  interesting  point  in  the  diagnosis 
of  adhesions  presented  itself  to  me  some 
years  ago.  A  tumour,  which  had  not 
been  tapped,  was  observed  to  move  very 
freely  beneath  the  abdominal  parietes  on 
deep  inspiration,  and  I  therefore  expected 
to  find  it  non-adherent.  But  at  the  ope- 
ration on  June  13,  18C4,  firm  adhesions 
anteriorly  and  in  the  right  iliac  fossa, 
sufficiently  long  to  admit  of  the  cyst 
moving  freely,  and  an  extensive  surface 
of  adherent  omentum,  were  separated  by 
the  hand  with  some  difficulty,  and  a  close 
adhesion  to  the  fundus  of  the  bladder 
required  careful  dissection. 

The  action  of  the  recti  abdominales 
varies  with  the  different  conditions  of 
ovarian  tumours,  and  should  be  brought 
into  view  by  directing  the  recumbent 
patient  to  try  and  sit  up  without  assisting 
herself  by  her  hands  or  elbows.  This 
effort  puts  the  recti  in  strong  action,  and 
if  a  tense  ovarian  cyst  is  free  from  adhe- 
sion, it  falls  backwards  and  to  the  sides, 
while  the  muscles  form  a  projecting 
ridge  in  the  centre  of  the  abdomen.  The 
same  ap^^earance  is  seen  in  cases  of  adhe- 
rent cyst  ordy  when  it  is  flaccid  or  partially 
empty. 

The  umbilicus  is  not  affected  by  the 
movements  of  a  free  ovarian  cyst  during 
respiratory  action,  or  when  pushed  in 
various  directions.  But  any  movement 
communicated  to  a  cyst  which  adheres  to 
the  front  of  the  abdominal  wall  is  imme- 
diately followed  by  a  corresponding  move- 
ment of  the  naA'el. 

But  while  slight  adhesions  to  the  ab- 
dominal wall  are  not  much  regarded  in 
ovariotomy,  adhesions  low  down  in  the 
pelvis  are,  on  the  contrary,  of  great  im- 
portance. The  difficulty  is  to  separate 
them  without  injury  to  the  rectum  or  the 
bladder,  or  the  ureters,  or  to  large  blood- 
vessels or  to  nerves,  and  it  is  not  easy  to 
find  every  bleeding  vessel  or  to  stop  the 
loss  of  blood.  When  deep  seated  and 
very  intimate,  the  dissection  necessary  is 
out  of  the  question  in  the  living  patient, 
and  gives  no  small  trouble  after  death. 
Such  a  condition  may  be  suspected,  espe- 
cially after  tapping,  Avhen  placing  the 
patient  on  her  elbows  and  knees,  with 
the  pelvis  raised  and  the  thorax  de- 
pressed, the  lower  ])ortion  of  the  tumour 
can    be    felt    unyielding    by    the    finger 


THE   PEDICLE 


through  the  vagina  or  rectum,  and  the 
uterus  is  either  pulled  up  out  of  reach, 
or  pressed  backwards  or  forwards  or  to 
either  side,  while  its  mobility  is  consi- 
derably restricted. 

But  it  is  quite  possible  that  the  lower 
portion  of  an  ovarian  tumour  may  be 
jammed  downwards  and  moulded  into  the 
pelvis  Avithout  becoming  attached.  Then 
in  the  same  position  some  force  with 
the  finger  will  dislodge  it  and  show  that 
it  is  not  bound  down  by  adhesions.  I 
have  operated  on  an  ovarian  tumour  thus 
simply  impacted  in  Douglas's  space  with 
the  uterus  thrust  upwards  out  of  the 
pelvis.  Both  ovaries  were  diseased,  and 
though  there  were  no  adhesions,  one  cyst 
was  prevented  from  rising  by  the  other. 
They  were  successfully  removed.  It  is 
curious  in  such  cases  to  hear  the  rush 
of  air  into  the  hollow  Avheu  the  lower 
portion  of  the  cyst  is  pulled  away  from 
the  sacrum.  The  air  passes  down  with  a 
gurgling  sound,  and  the  tumour  is  brought 
away  with  no  more  than  the  ordinary 
difficulty. 

Adhesions  to  the  liver,  stomach,  or 
spleen  can  never  be  accurately  made  out 
before  operation.  Sometimes  a  coil  of 
intestine  can  be  distinctly  traced,  always 
remaining  attached  to  the  samepart  of  the 
cyst  wall.  Further  than  this,  adhesions  to 
the  abdominal  viscera  can  only  be  ascer- 
tained after  the  operation  has  been  com- 
menced. 

THE    PEDICLE 

For  the  gake  of  convenience,  the 
attachment  of  ovarian  cysts  and  tumours 
to  the  part  from  which  they  spring, 
whether  long,  narrow,  and  cord-like, 
or  short,  thick,  and  broad,  may  be  con- 
sidered imder  the  common  designation 
of  pedicle.  It  consists  of  the  Fallopian 
tube  often  much  elongated,  the  broad 
ligament  often  considerably  thickened, 
the  utero- ovarian  ligament  in  some  cases 
bypertrophied  into  a  large  fibroid  stem, 
and  the  round  ligament.  The  round  liga- 
ment may  be  so  convoluted  that  a  double 
curve  of  it  is  included  in  the  pedicle,  but 
it  is  often  quite  free.  Occasionally  the 
utero-ovarian  ligament  and  the  Fallopian 
tube  are  not  connected  by  the  broad  liga- 
ment; a  considerable  space  may  intervene 
between  them,  so  that  they  appear  as  two 
pedicles  to  one  tumour.  -The  pedicle  con- 
tains large  blood-vessels ;  every  now  and 
then  the  veins  are  so  large  and  distended 


that  they  resemble  the  intestines  of  a 
rabbit.  In  all  cases  of  ovarian  tumour 
the  arteries  are  branches  from  those  which 
supply  the  ovary  itself,  and  the  veins  have 
the  tortuous  distribution  peculiar  to  the 
plexuses  of  this  part.  Tlie  size  of  these 
vessels,  when  adhesions  do  not  materially 
contribute  to  the  supply  of  nourishment, 
is  mostly  in  proportion  to  the  bulk  of  the 
tumour ;  but  oftentimes  their  volume  is 
inexplicably  large,  and  accounts  for  the 
rapid  loss  of  blood  when  ruptured  or 
divided.  Numerous  lymphatics,  after  a 
devious  course  and  many  inosculations 
passing  between  the  ovary,  the  tube,  and 
the  broad  ligament  to  the  lumbar  plexus, 
are  also  inclosed  in  the  pedicle.  Nerves 
of  considerable  size  accompany  the  ve'ssels. 
I  have  seen  a  nerve  quite  as  large  as  the 
radial  in  a  part  of  the  pedicle  left  above 
the  clamp.  The  tissues  mixed  up  with 
the  other  components  of  the  pedicle  are 
histologically  the  same  as  those  of  the 
coats  of  the  tumour — a  species  of  imper- 
fect connective  and  fibrous  tissues,  the 
chief  elements  being  single  white  fibres, 
numerous  fusitbrm  embryonic  fibres,  and 
elliptical  round  cells  or  granules,  the 
whole  strongly  contractile,  coherent, 
and  bound  together  by  an  envelope  of 
peritoneum.  In  many  cases,  especially 
where  the  disease  assumes  the  colloid 
form,  the  pedicle  becomes  implicated,  is 
soft  in  texture,  and  easily  broken  through. 
In  others  it  becomes  the  seat  of  numerous 
proliferous  outgrowths  or  papillary  excres- 
cences. In  its  ordinary  form  it  is  exten- 
sible, and  of  variable  length  and  thickness. 
When  elongated,  it  may  form  attachments 
to  the  surrounding  parts,  and  sometimes 
is  the  cause  of  strangulation  of  intestine. 
It  is  not  often  that  it  is  seen  so  long  as  in 
Case  603,  where  it  measured  more  than 
one  foot,  and  was  accompanied  through- 
out by  the  Fallopian  tube.  In  Case  844 
it  was  more  than  the  usual  length,  and 
had  a  band  of  adhesion  stretching  across 
to  a  coil  of  intestine.  This  I  ligatured 
before  putting  on  a  clamp  to  the  pedicle. 
There  are  also  instances  of  duplicate 
pedicles.  I  need  only  cite  two  or  three 
cases  among  my  last  five  hundred.  In 
one  case  (502)  the  pedicle  was  in  two 
divisions  v;ith  intestine  between  them. 
Two  distinct  pedicles  supported  the  cyst 
in  Case  927,  but  the  tube  only  was  tied. 
The  patient  did  Avell.  In  Case  841,  I  met 
with  the  singular  complication  of  four 
cysts  for  which  there  were  four  pedicles. 


OVAIUAX  AND   ALLIED   TUMOURS 


ROTATION    OF    THE    PEDICLE 

A.  long  pedicle  allows  free  scope  to  tlie 
disposition  Avhich  these  tumours  have  to 
turn  upon  themselves,  and  is  then  the 
Bource  of  important  complications.  Li 
1865  Eokitansky  published  a  paper  on 
'  The  Strangulation  of  Ovarian  Tumoiirs 
by  Eotation.'  The  tumour  turns  upon 
its  axis,  and  the  pedicle  is  twisted  some- 
times as  much  as  two  or  three  times 
round.  The  occurrence  is  not  at  all  rare. 
Eokitansky  has  given  the  particulars  of 
thirteen  cases,  eight  of  which  he  found  in 
making  autopsies  after  fifty-eight  deaths 
from  ovarian  disease.  The  same  thing 
has  been  observed  during  my  operations 
in  more  than  twenty  cases,  and  no  doubt 
it  has  in  others  escaped  notice.  In  two 
cases  it  caused  death  before  operation. 

The  direction  of  this  rotation  is  not 
at  all  constant;  sometimes  being  inwards 
towards  the  median  line,  sometimes  the 
reverse,  outwards.  The  tumour  may  also 
rotate  obliquely,  turning  over  backwards 
or  forwards.  In  outward  rotation  the 
Tallopian  tube,  if  not  adlierent  to  the 
tumour,  becomes  spiral  round  the  pedicle ; 
if  adherent,  round  both  tumour  and  pedi- 
cle. In  inward  rotation,  the  first  half 
turn  pushes  the  tube  inwards  and  back- 
wards. Should  the  rotation  continue, 
then  the  tube  forms  a  spiral  round  the 
back  of  the  tumour.  Or  it  may  be 
altogether  exempt  from  participation  in 
the  turning.  The  uterus  is  pulled  in 
the  direction  of  the  rotation,  and  in  one 
case  (lOG)  it  was  so  much  drawn  out  of 
its  place  that  I  was  led  to  suppose  I  should 
find  close  adhesions,  which,  however, 
did  not  exist.  These  movements  seem 
occasionally  to  take  place  suddenly  and 
quickly ;  but  they  are  gradual  in  other 
cases ;  may  be  reversed,  and  recur. 
Where  the  rotation  is  not  complete,  the 
motion  may  become,  as  it  were,  slowly 
oscillating.  The  pedicle  sometimes  gives 
indications  of  these  changes  having  taken 
place  repeatedly  ;  and  general  symptoms, 
Buch  as  sudden  accession  or  increase  of 
pain,  change  of  other  sensations  from 
altered  relative  position  of  the  tumour 
and  viscera,  and  perhaps  some  difference 
in  the  external  contour  of  the  belly,  may 
enable  us  to  conjecture  tlie  time  of  com- 
mencing rotation. 

But  if  the  pedicle  has  become  twisted, 
and  no  imwinding  of  it  follovvs,  what  may 
be    the  consequences?      The  great  veins 


are  compressed,  and  blood  continues  to 
pour  in  by  the  arteries.  Congestion, 
exudation  of  serum,  extravasation  of 
blood  into  the  cysts,  and  rupture  follow 
in  rapid  succession ;  and,  unless  timely 
relief  is  afforded  by  ovariotomy,  the 
patient  soon  sinks.  If  the  rotations  are 
so  complete  as  to  strangulate  the  arteries 
of  the  pedicle,  gangrene  is  inevitable. 
But  supposing  the  revolving  of  the 
tumour  to  be  accomplished  more  tar- 
dily, nutrition  is  only  impeded,  and 
the  more  happy  result  of  shrivelling  of 
the  w^alls  of  the  tumour,  with  absorption 
of  the  contents,  may  occur.  The  remains 
of  such  tumours  have  been  found  some- 
times in  Douglas's  space  as  a  hard,  solid, 
partly  cartilaginous  substance.  Inflam- 
matory adhe^ions  binding  down  the  pedi- 
cle have  also,  without  twisting,  brought 
about  the  atrophy  of  an  ovarian  tumour. 
In  other  instances,  the  constriction  of  the 
vessels  by  the  change  of  position  is  so 
moderate  that  the  tumour  itself  is  not 
much  affected,  but  it  remains  stationary, 
contracts  adhesions  to  some  of  the  viscera, 
and  cannot  be  replaced.  Rokitansky 
mentions  one  case  in  which  a  strong 
cord-like  band  so  compressed  the  sigmoid, 
flexure  of  the  colon  that  the  slightest 
change  of  position  rendered  it  imper- 
meable. Tlie  bowel  has  also  been  so 
entangled,  with  a  long  pedicle,  during 
rotation,  as  to  become  strangulated.  The 
immediate  performance  of  ovariotomy 
might  be  rendered  necessary,  under  such 
circumstances,  for  the  release  of  the  com- 
pressed and  obstructed  intestine.  Even 
after  new  vascular  alliances  have  been 
formed  between  the  rotated  tumour  and 
the  omentum  or  viscera,  the  pedicle  has 
by  some  means,  either  tension  or  pressure, 
been  divided.  In  such  a  state  of  ti'ans- 
plantation,  the  tumour  has  drawn  its 
nutriment  through  the  newly  formed 
vessels  of  the  plastic  adhesions,  and  its 
parasitic  existence  has  not  been  much 
less  vigorous  than  before.  Several  ex- 
amples of  these  self-grafted  tumours  have 
come  imdcr  notice  among  my  ovario- 
tomies. In  the  operation  in  Case  110 
there  was  no  adhesion  of  the  cyst  to  the 
abdominal  wall,  Imt  the  omentum  was 
strongly  attached  to  the  upper  part  of  the 
cyst,  and  interlaced  with  mesentery  from 
below.  I  tapped  several  large  cysts  suc- 
cessively, got  the  tumour  out,  and  then 
found  there  was  no  pedicle.  It  appeared 
that    the    tiuiiour    derived    its   vascular 


ROTATION   OF   THE   PEDICLE 


siippiy  solely  from  the  omental  and 
mesenteric  vessels.  The  fundus  of  the 
uterus  felt  rough,  but  there  v/as  no  tear 
nor  fracture  at  the  point  where  the  Fal- 
lopian tube  must  have  separated,  nor  was 
there  any  bleeding ;  there  was  pretty  free 
hajmorrhage  from  the  omental  vessels. 
I  cut  away  some  shreds  of  omentum,  and 
tied  at  least  twelve  vessels  with  very  fine 
silk,  cutting  off  both  ends  of  the  ligatures 
close,  and  returning  the  omentum  with  the 
tied  vessels  into  the  abdomen.  The  other 
ovary  was  found  in  its  natural  position, 
but  enlarged  and  diseased.  It  too  was 
removed,  and  the  patient  was  soon  fully 
I'e-established  in  health,  and  lived  till  the 
year  1878.  Another  instance  (Case  419) 
was  that  of  a  woman  thirty-eight  years  of 
age,  with  five  children,  who  for  eighteen 
years,  and  through  all  her  pregnancies, 
had  carried  a  dermoid  cyst.  When  two 
months  advanced  in  pregnancy  (May 
1871)  I  operated  on  her  without  hindrance 
to  the  gestation.  The  tumour  being  der- 
moid, its  contents  would  not  pass  through 
the  trocar,  but  gushed  out  from  the  punc- 
ture. The  cyst  was  then  drawn  out,  lai'ge 
shreds  of  very  vascular  omentum  and  a 
•coil  of  intestine  growing  to  it.  On  separat- 
ing the  omentum  and  intestine,  it  was 
found  that  there  was  no  pedicle.  The 
Jolood  supply  of  the  cyst  had  been  kept  up 
by  the  omental  vessels,  and  some  large 
vessels  near  the  ca^cal  a]ipendix,  where  the 
intestine  appeared  thick  and  contracted. 
Several  vessels  and  shreds  of  omentum 
were  tied,  and  returned  with  the  ligatures 
cut  off  short.  At  the  full  term  of  preg- 
nancy a  living  child  was  born,  alter  a 
natural  labour,  in  December  1871.  The 
patient  was  well  in  1872,  but  in  1881 
suffered  from  pulmonary  disease,  which 
afterwards  proved  fatal. 

It  is  very  easy  to  understand  that  an 
ovarian  tumour  of  almost  any  size,  pro- 
vided the  pedicle  be  long  and  the  tumour 
be  free  from  adhesion,  may  rotate  and  form 
one,  two,  or  more  complete  twists  of  the 
pedicle.  I  have  several  times  unrolled 
the  pedicle  before  applying  a  clamp  or 
ligature,  turning  round  the  tumour  three 
or  four  times  before  it  was  set  right — 
although  there  had  been  no  such  stop- 
page of  the  supply  or  return  of  blood 
as  to  have  affected  in  any  remarkable 
degree  the  nutrition  or  appearance  of  the 
tumour.  But  in  other  cases,  the  veins 
liaving  been  compressed  while  the  arterial 
supply  went  on,  successive   hosmorrhages 


have  taken  place.  I  have  twice  known 
sudden  death  so  caused.  I  once  went  with 
the  late  Mr.  Fowler,  of  Kennington,  to 
operate  upon  a  lady  at  Brixton,  when 
we  found  that  she  had  died  unexpectedly 
two  hours  before  our  arrival.  The  post- 
mortem examination  showed  that  death 
was  due  to  a  very  large  extravasation  of 
blood,  first  into  the  ovarian  cyst  and  then, 
after  its  bursting,  into  the  abdominal 
cavity,  evidently  the  consequence  of  a 
complete  twist  of  the  pedicle  by  the 
rotation  of  a  non-adherent  cyst.  In 
another  case  I  went  to  the  Hospital  for 
Incurables  at  Putney  to  see  a  patient 
there  by  the  desire  of  Mr.  Cream.  She 
had  been  found  dead  that  morning  by  the 
side  of  her  bed.  I  opened  her  abdomen 
and  removed  a  large  free  ovarian  cyst, 
which  contained  more  than  five  pounds  of 
blood-clot,  the  bleeding  in  this  instance 
also  caused  by  a  long  twisted  pedicle. 
These  are  the  only  two  cases  of  sudden 
death  I  have  seen,  but  I  have  many  times 
known  htemorrhage  to  a  smaller  extent 
lead  to  attacks  of  pain,  vomiting,  and 
supposed  peritonitis ;  and  more  than  once 
such  extreme  pallor  or  chloro-ana;mic 
aspect  as  gave  rise  to  ungrounded  fear  of 
malignant  disease.  One  very  remarkable 
case  of  this  kind  was  a  lady  from  Moscow, 
who  arrived  in  London,  May  1879,  after 
a  journey  which  was  interrupted  at  Berlin 
by  an  attack  of  severe  abdominal  pain  and 
vomiting.  She  was  twenty-four  years  of 
age,  married  in  January  1873,  had  her 
first  child  in  November  of  that  year, 
aborted  in  1875,  1876,  and  1877,  and 
gave  birth  to  a  second  child  in  October 
1878.  In  1876,  before  the  second  abor- 
tion, she  observed  a  tumour  the  size  of 
the  fist  on  the  left  side  of  the  abdomen. 
Alter  the  abortion  it  increased  to  the  size 
of  a  child's  head,  and  so  remained  during 
the  subsequent  pregnancies.  The  last 
labour  was  natural,  but  the  abdomen  con- 
tinued to  enlarge  until  she  left  Moscow 
for  England  to  consult  me.  She  was  de- 
tained a  week  in  Berlin  by^  the  symptoms 
above  noticed,  attributable,  I  believe,  to 
a  twist  of  the  pedicle,  and  on  reaching 
London  she  was  suffering  from  a  recur- 
rence of  pain  and  vomiting.  She  was 
extremely  weak,  and  so  very  white  and 
bloodless  that,  fearing  no  time  was  to 
be  lost,  I  operated  after  she  had  been 
three  days  in  London  ;  and  found,  as  I  ex- 
pected, a  quantity  of  blood-clot  within  a 
very  rotten  cyst,  and  a  narrow  cord-like 


10 


OVARIAN   AND   ALLIED   TUMOURS 


pedicle  so  tightly  twisted  as  to  be  almost 
broken  off.  There  was  no  fetor.  Ex- 
tensive recent  adhesions  to  omentum  and 
coils  of  intestine  had  mainly  kept  up  the 
supply  of  blood  to  the  tumour  of  the  leit 
ovary.  The  right  ovary,  being  enlarired 
and  cystic,  was  also  removed.  The 
patient  recovered  without  any  fever,  soon 
regained  her  colour,  and  sent  me  a 
coloured  photograph  portrait  to  show  the 
difference  between  her  striking  pallor 
before  the  opeiati(m  and  her  look  of 
blooming  health  afterv/ards. 

The  generality  of  sessile  tumours, 
extra-ovarian  and  retro-peritoneal,  have 
no  true  pedicle,  but  acquire  their  supply 
of  blood  by  numerous  vessels  entering  at 
all  the  attached  parts.  Sonni  of  the  retro- 
peritoneal,   however,    in    enlarging    from 


their  base,  drive  the  peritoneum  before 
them.  This  then  makes  a  band  or  cord 
of  connection,  and  may  or  may  not  contain 
a  few  large  vessels,  but  does  not  assume 
the  form  of  a  stem  as  in  ovarian  cysts. 
The  pi'oportion  of  cases  in  which  there  is 
a  true  pedicle — long  or  short — and  those 
where  the  connection  of  the  base  of  the 
cyst  to  the  surrounding  parts  is  so  intimate 
that  separation  can  only  be  effected  by  a 
sort  of  enucleation  is  not  very  easy  to 
estimate'  exactly  ;  because  when  the  base 
is  small  and  may  be  surrounded  by  a 
ligature,  many  would  call  this  a  short 
pedicle.  But,  speaking  roughly,  I  should 
say  that  in  my  practice  I  have  not  met 
with  more  than  5  per  cent,  where  true 
enucleation  has  been  necessary. 


CHAPTER  II 


DIFFERENTIAL    DIAGNOSIS    OF    OVAUIAN    TUMOUIIS 


"When  a  woman  with  enlarged  abdomen 
comes  under  naedical  examination  the' 
three  inevitable  questions  rise  up  for  de- 
termination :  1st.  Has  she  an  ovarian 
tumour,  or  is  it  something  else  which  can 
give  rise  to  the  same  symptoms  and  ap- 
pearances ?  2nd.  If  she  has  an  ovarian 
tumour,  of  what  kind  is  it,  and  how  can 
Ave  distinguish  one  kind  from  another  ? 
and  3rd.  Are  there  any  other  abdominal 
conditions  and  diseases  of  enlargement  co- 
existing with  it  and  disguising  its  identity, 
modifying  its  progress,  or  influencing  our 
views  as  to  its  treatment  ? 

The  first  point,  therefore,  which  has  to 
be  considered  in  studying  a  case  of  abdo- 
minal swelling  is  the  organ  from  which  it 
ai'ises.  The  presumption  being  on  the 
side  of  an  ovarian  tumour  from  the  exist- 
ence of  a  certain  set  of  signs  and  S3'mptoms, 
the  probability  of  its  being  simulated  by 
some  other  disease  has  to  be  discussed. 
And  there  are  many  conditions — some 
morbid,  otliers  natural — which  may  give 
rise  to  doubt  and  difKculty  in  coming  to  a 
decision  ;  though  these  diagnostic  puzzles 
vary  much  in  force  according  to  their 
nature  and  the  conditions  under  which 
they  offer  themselves. 

After  the  following  enumeration  of  the 
principal  states  and   diseases  which   jnay 


throw  doubt  on  the  diagnosis  of  an  ovarian 
tumour,  or  for  which  it  may  be  mistaken, 
I  shall  proceed  to  the  sepaiate  considera- 
tion of  the  most  important.  In  connection 
with  the  peritoneum  we  have  : 

Ascites, 

Encysted  dropsy  of  the  peritoneum, 
Tympanites  and  phantom  tumours, 
Fibro-plastic  tumours  of  peritoneum, 
Fatty  and  other  tumours  of  omen- 

tuni  and  mesentery. 
Hydatids, 
Cancer  and  tubercle. 

Difficulties   in    diagnosis    caused   by 
uterine  enlargements  :a-ise  from  : 

Pregnancy, 

Retained  menses  and  moles. 

Air  and  fluids  in  uterus  or  Fallopian 

tubes. 
Fibroid  tumours. 
Cancer. 

Another  miscellaneous  group  is  this  : 

Hypertrophy  of  the  abdominal  wall, 
Enlargements  of  other  viscera,  such 
as  the  liver,  spleen,  kidney,  and 
luml)ar  and  mesenteric  glands. 
Hydatid    cysts   of  the    liver,  gall- 
stones, 


DIFFERENTIAL  DIAGNOSIS  OF  OVARIAN  TUMOURS 


11 


Movable  kidney,  and  cysts  and  tu- 
mours of  the  kidney, 

Fascal  accumulations, 

Distended  bladder, 

Hajmatocele, 

Pelvic  abscess, 

Extra-uterine  pregnancy, 

Enchondroma,  or  encephaloid  dis- 
ease of  ilium  or  vertebra?. 

Many  of  the  evils  and  discomforts 
Avhich  accompany  the  progress  of  a  case 
of  ovarian  tumour  arise,  no  doubt,  from 
its  mere  mechanical  interference  with  the 
organs  in  the  chest,  pelvis,  and  abdomen, 
displacing  and  compressing  them,  impair- 
ing their  nutrition,  and  disturbing  their 
functions.     But  the  pressure  of  the  gravid 


uterus  is  as  great,  or  even  greater,  and  a 
pregnant  woman  has  sometimes  to  endure 
real  miseries.  Still  the  process  is  natural, 
and  there  are  compensations  in  the  shape 
of  local  adjustments,  and  temporary 
accommodating  changes  of  form  and 
moral  influences,  -which  are  wanting  to 
the  victim  of  ovarian  disease.  Instead 
of  being  cheered  by  the  hopes  and  aspira- 
tions of  maternity,  she  has  to  bear  the 
torture  of  suspense  or  despair  ;  her  blood 
is  impoverished  and  her  nervous  system 
shattered  by  imperfect  assimilation.  After 
a  time,  the  emaciation  always  going  on, 
and  the  weary,  ceaseless  self-watchings, 
made  inevitable  by  the  incapacity  to  use 
healthful   exercise    or   to   undertake   the 


usual  occupations  with  success,  chisel  out 
the  features  into  the  peculiar  pinched 
expression  which  has  been  described  as 
the  fades  uteriaa,  but  which  would  pro- 
bably be  better  named  fades  ovariana. 

This  drawing,  an  exact  copy  of  a  photo- 
graphic portrait,  gives  a  very  correct  idea 
of  the  peculiar  physiognomy.  The  ema- 
ciation, the  prominent  or  almost  uncovered 
muscles  and  bones,  the  expression  of 
anxiety  and  suffering,  the  furrowed  fore- 
head, the  sunken  eyes,  the  open  sharply- 
defined  nostrils,  the  long  compressed  lips, 
the  depressed  angles  of  the  mouth,  and 
the  deep  wrinkles  curving  round  these 
angles,  form  together  a  face  Avliich  is 
strikingly  characteristic. 


The  tumour  begins  to  grow  on  one 
side,  where  it  occupies  space  wanted  for 
the  large  intestine  with  its  accumulations, 
and  no  provision  is  made,  as  for  the  uterus, 
for  its  expansion  or  for  the  due  mainte- 
nance of  its  relative  position  in  respect  to 
the  viscera.  All  is  irregular  and  wrong. 
At  first  the  weight  makes  it  settle  down 
into  the  pelvis,  where  it  causes  irritation 
of  the  bladder  and  rectum.  Mounting 
higher  with  augmenting  bulk,  it  presses 
on  the  large  intestine,  according  to  side, 
and  fa;cal  matter  is  impacted.  The  uterus 
is  displaced,  thrust  do-wn,  or  to  one  or  the 
other  side,  retroverted  or  anteverted ;  and, 


12 


OVARIAX   AND   ALLIED   TUMOURS 


•as  the'  case  advances,  is  sometimes  so 
dragged  up  by  its  attachments  to  the  tu- 
mour as  to  be  out  of  reach  of  the  finger 
in  the  vagina.  Its  form  is  distorted  and  its 
functions  rendered  difficult  and  painful, 
though  not  absolutely  impossible  ;  for,  as 
it  has  been  already  seen,  tliere  are  many 
coincident  cases  of  pregnancy  and  ovarian 
disease.  The  urinary  organs  seldom 
escape  at  any  stage  of  the  disease. 
When  the  pressure  is  on  the  bladder, 
micturition  is  either  troublesome,  impos- 
sible, or  distressingly  urgent.  With 
strain  upon  or  pinching  of  the  ureters, 
there  may  be  stoppage  of  the  flow  of  urine, 
or  suspension  of  its  secretion,  or  poisonous 
ireflux  into  the  system.  Even  the  kidneys 
anay  be  flattened  and  almost  annihilated. 
The  vital  organs  in  the  chest  suffer  in 
cnany  ways,  and  the  chest  symptoms  of 


oppressed  action  are  often  among  the 
most  tormenting.  (Edema,  ascites,  and 
pleural  effusion,  especially  on  the  right 
side,  occasion  the  greatest  aggravation  of 
misery ;  and  the  effects  of  distension 
upon  the  ribs  and  spine  are  so  opposed  to 
readjustment  as  to  amount  to  serious 
hindrance  to  recovery  after  tapping. 
More  than  once  the  ribs,  which  have  been 
thrown  out  like  a  fan,  with  the  intercostal 
structures  overstretched,  have  never  re- 
turned to  their  normal  condition.  The 
lungs,  which  have  been  confined  to  a  very 
small  space,  had  so  far  lost  their  resiliency 
that  air  could  not  easily  expand  them 
again.  The  pleural  cavities,  filled  with 
fiuid,  have  not  been  freed  by  absorption, 
or  the  lung  has  not  expanded  after  tapping, 
and  the  patient  has  died  from  want  of 
breathing  power.     Occasionally  the  same 


^V¥    m  ^ 


'difliculty  has  been  met  with  after  ovario- 
toniy  ;  and  a  patient,  in  whom  repair  has 
gone  on  well  so  far  as  the  abdomen  was 
•concerned,  has  had  her  recovery  greatly 
retarded,  or  has  died,  simply  in  conse- 
v|uence  of  the  state  of  her  chest.  The 
two  accompanying  copies  of  photographic 
■portraits  show  well  how  limited  the  breath- 
ing space  sometimes  liecomes  in  conse- 
t'luence  of  the  excessive  growth  of  a 
tumour. 

DIAGNOSIS     BETWEEN     OVAUIAN     DIlOPSY 
AND    ASCITES 

Our  senses  of  sight,  touch,  and  hearing 
-are  all  required  to  assist  us  in  distinguish- 
ing ascites  from  ovarian  dropsy,  the 
physical  diagnosis  being  established — I. 
By  inspection  and  measurement;  IF.  By 
palpation;   III.  By  percussion  and  auscul- 


tation ;  and  IV.  By  chemical  and  micro- 
scopical examination  of  the  tluids. 

I.  Jnsjiection. — The  si:e  of  the  ab- 
domen is  seen  to  be  increased  both  in 
ascites  and  in  ovarian  dropsy  ;  and,  when 
an  ovarian  cyst  is  large,  the  abdominal 
enlargement  is  general,  as  it  is  in  ascites. 
But  while  the  cyst  is  of  moderate  size,  the 
abdominal  enlargement  is  often  partial, 
more  to  one  side  than  the  other,  more 
below  the  umbilictis  than  above. 

In  form,  the  flanks  and  sides  of  the 
abdomen  protrude  in  ascites,  the  front  not 
being  more  convex  tlian  in  the  natural 
state,  or  it  may  be  flattened  :  while  in 
ovarian  disease  the  bulging  is  generally 
most  evident  in  front,  less  so  at  the  sides, 
and  often  more  on  one  side  than  the  other. 
These  remarks  apply  to  simple  cysts  only. 
Alterations  in  position  generally  produce 


DIFFERENTIAL   DIAGNOSIS   OF   OVARIAN   TUMOURS 


13; 


a  greater  and  more  immediate  change  in 
the  form  of  the  abdomen  in  ascites  than 
in  ovarian  disease,  the  free  fluid  gravitat- 
ing much  more  readily  than  a  cyst  can 
move.  The  normal  depression  of  the 
umbilicus  is  altered  whenever  the  general 
abdominal  enlargement  is  considerable 
both  in  ascites  and  ovarian  dropsy ;  but 
in  the  latter  disease,  although  the  navel 
may  be  flattened  as  in  pregnancy,  it  is 
only  prominent  and  bulging  (as  it  very 
often  is  in  ascites)  when  ascitic  fluid 
surrounds  an  ovarian  tumour,  or  when 
there  is  an  umbilical  hernia  also.  The 
superficial  veins  may  be  dilated  from  the 
lower  part  of  the  abdomen  to  the  chest,  on 
one  or  both  sides,  in  either  disease.  This 
varicose  state  of  the  veins  only  assists  in 
diagnosis  when  much  more  evident  on  one 
side  than   the    other.     Such    undue    im- 


portance has  been  given  to  this  vasculai: 
condition  as  a  distinction  between  ascites 
and  ovatian  dropsy,  and  between  simple 
and  maliprnant  tumours  within  the  ab- 
domen, that  the  following  facts  should  be 
recollected  : 

The  appearance  of  congestion  of  the 
episgastric  veins,  seen  merely  as  a  fine 
network  of  capillaries,  is  usually  a  simple 
result  of  absorption  of  the  cutaneous  ikr^ 
the  vessels  becoming  visible  through  the 
thinned  and  distended  skin,  and  has  no 
diagnostic  value.  When  some  of  the 
larger  veins,  dilated  or  varicose,  in  their 
course  from  the  inguinal  region  upwards^ 
either  cease  abruptly  in  the  middle  of  the. 
abdomen,  or  run  to  the  hypochondriac 
region,  or  even  up  to  the  clavicles,  an- 
astomosing with  branches  of  the  mammary 
and  intercostal  veins,  the  impediment  to 


the  circulation  may  be  of  several  kinds. 
It  may  be  either  in  the  heart,  the  trunk 
or  larger  branches  of  the  inferior  cava, 
or  in  the  Portal  system.  Pregnancy, 
tumours,  or  coagula  causing  obstruction 
in  any  of  these  vessels  will  throw  the 
circulation  into  the  epigastrics. 

When  the  integuments  are  oedematous, 
the  liness  albicantes  become  prominent, 
and  have  a  knotty  appearance,  which  has 
led  to  the  mistaken  appellation  of  varicose 
lymphatics.  I  have  observed  it  chiefly  in 
cases  of  tumour  surrounded  by  ascitic 
fluid. 

The  movement  on  respiration  is  defec- 
tive in  both  diseases,  both  as  regards  the 
soft  wall  of  the  abdomen  and  the  lower 
ribs,  while  that  of  the  upper  ribs  is  ex- 
aggerated. The  alteration  in  movement 
only  assists  in  diagnosis  when  it  is  partial 


or  affects  only  one  side.  On  making  deep 
inspirations  the  upper  part  of  an  ovarian 
cyst  may  often  be  seen  to  rise  and  fall. 
This  appearance  is  very  characteristic. 
In  ascites  it  may  be  simulated  by  some 
distended  coils  of  intestine  moving  with 
the  diaphragm  ;  but  the  2-esonance  of  the 
intestine  on  percussion  instantly  settles  ali 
doubt  on  this  point. 

On  measurement,  the  enlargement  of 
the  abdomen  in  ascites  is  equal  on  both 
sides,  or  symmetrical  ;  and,  although  the 
distance  from  the  sternum  to  the  pubes  is 
increased,  the  umbilicus  retains  its  normal 
position — about  an  inch  nearer  to  the 
pubes  than  to  the  sternum — and  is  about 
on  a  level  with  the  highest  point  of  the 
crest  of  the  ilium  on  each  side,  and  mid- 
way between  these  two  points.  In  ova- 
rian dropsy  there  is  often  a  considerable 


14 


OVARIAN  AND  ALLIED   TUMOURS 


alteration  in  tlie  measurements  between 
the  umbilicus  and  sternum,  and  umbilicus 
and  pubes,  as  well  as  between  the 
umbilicus  and  the  two  cristas  ilii.  In 
ascites  the  greatest  circular  measurement 
is  at  the  level  of  the  umbilicus ;  in  ovarian 
dropsy  it  is  often  some  inches  lower  down. 
II.  On  palpation,  the  abdominal  wall, 
in  both  diseases,  is  felt  to  be  harder  and 
more  resistant  than  natural,  in  the  parts 
made  tense  by  much  fluid,  but  is  soft  and 
elastic  elsewhere.  Consequently  the  varia- 
tion in  the  seat  of  hardness  Avith  the 
position  of  the  patient  becomes  useful  in 
diagnosis,  the  fluid  in  ascites  gravitating 
freely  to  the  most  dependent  part.  Fluc- 
tuation is  perceived  with  varying  distinct- 
ness according  to  the  degree  of  tension  of 
the  abdominal  wall,  to  the  thickness  of 
the  layer  of  flit,  to  the  amount  of  osdema, 
to  the  thickness  of  the  peritoneum  or  of 


the  cyst,  to  the  quantity  and  character 
of  the  fluid,  and  to  the  amount  of  tym- 
panitic distension  of  the  intestines.  It 
occasionally  happens  that  the  abdomen  is 
too  forcibly  distended  to  respond  to  the 
stroke,  and  gives  no  sign  of  fluctuation. 
In  itself,  fluctuation  offers  no  assistance 
in  diagnosis,  because  a  thin-walled  ovarian 
cyst,  filled  with  limpid  fluid,  with  a 
moderately  tense  and  thin  abdominal 
wall,  would  give  a  more  quick  and 
decided  wave  than  a  moderate  quantity 
of  ascitic  fluid  beneath  an  abdominal  wall 
thickened  by  fat  or  subcutaneous  oedema. 
The  characteristic  peculiarity  of  the 
fluctuation  in  ascites  is  that  it  varies  with 
the  position  of  the  patient,  and  is  only 
perceived  in  the  parts  where  the  fluid 
gravitates  towards  the  abdominal  wall ; 
while  in  ovarian  dropsy  its  situation  does 
not  vary  with  position,  bitt   is  perceived 


wherever  fluid   is   to   be    discovered  by 
percussion. 

III.  Percussion  and  auscultation. — 
The  two  preceding  diagrams  represent  the 
situation  of  clear  and  dull  soimda  obtained 
by  percussion  in  typical  cases  of  ascites 
and  ovarian  disease,  the  patient  lying 
flat  and  evenly  on  her  back.  The  dark 
parts  of  the  abdomen  are  dull,  the  rest 
clear.  In  ascites,  the  stomach  and  intes- 
tines are  above  and  in  front ;  the  fluid, 
behind  and  on  either  side.  In  ovarian 
dropsy  the  fluid  is  in  front,  extending 
in  different  degrees  to  either  side, 
and  pushing  the  stomach  and  intestines 
upwards  and  backwards,  just  as  a  gravid 
uterus  does.  The  figure  to  the  right  of 
the  page,  indeed,  would  represent  either 
a  gravid  uterus  near  the  full  period  of 
jn-egnancy,  or  an  ovarian  cyst  of  about 
the  size  of  such  a  uterus,  and  situated 
centrally,  as  many  ovarian  cysts  are  at 


this,  or  a  rather  later,  period  of  their 
growth.  But  quite  as  irequently  they 
tend  towards  one  side  or  the  other,  in 
such  cases  the  diagnosis  being,  of  course, 
easier. 

It  is  seldom  that  a  patient  with  ascites 
lies  so  flat  as  not  to  raise  the  shoulders 
enough  to  throw  a  layer  of  fluid  down- 
wards towards  the  pubes.  Very  often  the 
dulness  may  extend  as  high  as  the  um- 
bilicus, and  it  generally  does  so  when  the 
shoulders  are  miich  raised  by  pillows. 
This  might  lead  a  superficial  observer 
to  suppose  that  the  disease  was  ovarian, 
because  there  was  a  dull  sound  in  the 
front  of  the  abdomen ;  but  on  lowering 
the  shoulders  and  placing  a  pillow  imder 
the  hips,  the  fluid  at  once  gravitates 
towards  the  diaphragm,  the  intestines 
float  to  the  .surliace,  and  a  clear  sound  is 
obtained  where  it  was  dull  before.  No 
such  alteration  in  the  situation  of  dulness 


DIFFERP^NTIAL  DIAGNOSIS   OF  OVARIAN   TUMOURS 


15 


can  possibly  occur  in  ovarian  disease.  So 
on  turning  from  side  to  side,  the  ascitic 
fluid  flows  over  to  the  side  which  is  low, 
and  the  intestines  rise  to  the  upper  side, 
with  corresponding  changes  in  the  situa- 
tion of  dull  and  clear  sounds  on  percus- 
sion. This  does  not  take  place  in  ovarian 
disease.  Again,  in  ascites,  at  any  spot 
near  the  level  where  the  resonance  of  the 
intestines  ends,  and  the  dulness  of  the 
fluid  begins,  and  a  dull  sound  is  elicited 
by  gentle  pressure  and  percussion,  a 
deeper  pressure  Avill  displace  the  fluid, 
and  •  the  resonance  of  the  intestines  will 
be  heard.  At  the  most  depending  spots 
the  amount  of  pressure  necessary  to 
obtain  a  clear  sound  is  some  guide  to  the 
estimation  of  the  thickness  of  the  layer 
of  fluid.  Superficial  and  deep  percussion 
cannot  produce  such  difference  in  the 
sounds  in  ovarian  disease. 

When  fluid  is  free  in  the  peritoneal 
cavity  the  wave  of  fluctuation  may  be  felt 
not  only  where  the  sound  is  dull  on  per- 
cussion, but  also  beyond  the  line  of  dul- 
ness, even  Avhere  resonance  may  be  tym- 
panitic. The  intestines  float  in  the  fluid, 
and  the  fluid  may  be  thrown  in  waves 
among  them.  But  Avhen  fluid  is  con- 
tained within  a  cyst,  fluctuation  cannot 
be  detected  beyond  the  boundaries  of  the 
cyst.  Hence  the  outline  of  the  cyst, 
traceable  by  dulness  on  percussion,  and 
the  line  where  fluctuation  can  be  per- 
ceived must  be  the  same.  The  wave  of 
fluctuation  ends  at  the  limit  of  resonance. 

It  has  been  supposed  that  percussion 
on  the  loins  is  a  very  sure  guide  in  dia- 
gnosis— that  when  the  patient  is  sitting 
up,  and  one  loin  is  clear  and  the  other 
dull,  the  disease  is  ovarian,  but  that 
when  there  is  dulness  on  both  sides  it  is 
ascites.  One  dull  side  is  also  supposed 
to  be  a  proof  that  the  ovary  of  that  side 
is  the  one  diseased.  But  there  are  so 
many  exceptions  to  these  rules,  that  tliey 
are  of  no  great  value,  except  as  corrobo- 
rating or  counterbalancing  other  physical 
signs. 

Auscultation  alone  affords  little  in- 
formation, but  it  shows  the  presence  of 
the  gurgling  sounds  of  the  intestines  in 
the  spots  clear  on  percussion,  and  the 
absence  of  these  sounds  in  the  dull  spots, 
except  on  deep  pressure.  In  both  dis- 
eases the  fluctuation  wave  may  be  heard 
as  well  as  felt.  The  aortic  sounds  and 
impulses  are  transmitted  by  the  cystic 
and  solid  tum.ours,  but  not  by  ascites. 


By  applying  these  general  rules,  a  few 
seconds  will  enable  the  surgeon  to  clear 
up  all  doubt  in  any  ordinary  case.  But 
there  are  various  conditions  which  may 
lead  to  the  necessity  for  further  examina- 
tion. The  quantity  of  fluid  in  the  perito- 
neal cavity  may  be  so  large  that  the  firont 
of  the  abdomen  is  pushed  far  beyond  the 
reach  of  the  intestines.  They  float  as 
far  as  the  mesentery  will  allow  them,  but 
cannot  reach  the  surface  of  the  abdominal 
wall.  In  this  case  percussion  must  give 
a  dull  note  in  front  just  as  it  does  in 
ovarian  dropsy.  So,  too,  when  the  in- 
testines are  fixed  in  the  back  part  of  the 
abdomen  by  adhesions,  or  by  a  thickened 
omentum,  the  fluid  is  kept  to  the  front  as 
in  ovarian  dropsy. 

Or  an  ovarian  cyst  may  contain  air 
or  gas,  entering  either  from  a  perforating 
communication  with  intestine,  or  through 
the  Fallopian  tube,  or  forming  after  tap- 
ping and  decomposition  of  fluid.  Percus- 
sion then  gives  a  clear  note  in  front  or 
above,  and  a  dull  note  behind  or  below, 
as  it  does  in  ascites;  and  occasionally, 
where  there  is  a  mixture  of  air  with, 
fluid,  the  sound  so  well  known  as  metallic 
tinkling  may  be  heard — air  bubbling 
through  fluid — or  drops  of  fluid  fiilling 
in  the  cavity.  In  these  circumstances 
physical  diagnosis  alone  cannot  solve  the 
doubt,  and  we  have  to  consider  all  that 
can  be  learned  from  the  history  of  the 
case  and  the  general  condition  of  the 
patient.  So,  when  fluid  is  free  in  the 
peritoneal  cavity,  we  must  resort  to  tap- 
ping and  chemical  or  microscopical  inves- 
tigation before  we  can  decide  whether  the 
fluid  is  the  ordinary  non-inflammatory 
serum  which  transudes  into  the  cavity  in 
heart,  liver,  or  kidney  disease,  or  the  in- 
flammatory exudation  of  chronic  perito- 
nitis in  its  simple  or  its  tubercular  or 
cancerous  form,  or  whether  it  may  be 
ovarian  fluid  which  has  escaped  from  a 
perforated  or  ruptured  cyst. 

IV.  Chemical  and  microscopical  exa- 
mination of  the  fluids. — The  normal 
Graafian  follicle  of  the  healthy  ovary  con- 
tains a  minute  quantity  of  a  slightly 
albuminous  fluid  resembling  the  serum 
of  blood.  It  is  alkaline,  of  pale  yellow 
colour,  and  transparent.  It  is  not  ropy 
but  limpid,  readily  separating  into  minute 
drops.  It  contains  a  small  quantity  of 
a  substance  which  will  coagulate  when 
treated  with  acids  or  alcohol,  or  when 
exposed  to  a  raised  temperature.    It  holds 


IG 


OVArJAN   A>"D   ALLIED   TUMOURS 


in  suspension  spheroidal,  nucleated  epi- 
thelial cells  and  shreds  of  epithelium 
from  the  membrana  granulosa  of  the 
ovisac. 

After  the  ruptnre  of  the  ovisac  it 
would  appear  tliat  the  fluid  contents,  or 
'  ovarine,'  escape  into  the  peritoneal 
cavity ;  but  the  quantity  is  so  minute 
ihat  it  can  hardly  do  more  than  moisten 
the  fringes  of  the  Fallopian  tube. 

There    are  endless  differences  in  the 
contents  of  ovarian  cysts,  and  these  diffe- 
j-ences  seem  to  be  in  no  way  dependent 
on  the  form  of  the  cysts  or  the  anatomical 
arrangement   of  their  tissues.     Even  the 
many  strange  ejiithclial  developments  are 
not  accompanied  by  any  special  kind  of 
fluid.      In  the  simple  unilocular  cysts,  it 
is  most  common  to  find  a  perfectly  clear, 
colourless,  or  straw-coloured  fluid.     But 
it  is  not  always  so ;   for  all  gradations  of 
colour  and  thickness  occur,  and  epithelial 
cells  are  almost  always  floating  in  the  fluids. 
In  some  rare  cases   there  are  cholesterine 
crystals  which,  after  standinsr,  form  a  glit- 
tering  pellicle   on   the    surface.     But  al- 
though the  quantity  is  really  very  small, 
it  is  so  very  rarely   met  with  in  ascitic 
fluid,  that   its  appearance  may  almost  be 
looked  upon  as  diagnostic  of  the  others. 
True  albumen  may  be  present,  but  in  un- 
certain   proportions.       It  is    in    the  few 
cases  Avhere  it  is  absolutely  wanting  that 
simple    taj^ping    proves  curative.      Spon- 
taneously    coagulable    fibrine    is    hardly 
ever  a  constituent  of  the    simple    cystic 
fluids ;   a    character    which    distinguishes 
them   from  ascitic   effusions,  from  which 
there    is  almost   invariably   a   deposit   o£ 
fibrine  taking  the  form  of  elastic  filaments 
after  washing ;   the  deposit  froni  ovarian 
serum,  if  any,  being  soft  and  not  at  all 
elastic.     Ascitic  fluids  never  contain  more 
solid  matter  than  the  serum  of  the  blood, 
and      the     greater    niimber    of     ovarian 
fluids  have   even   less ;     but    any   serous  | 
fluid,    taken    from    the    abdomen    of    a  ! 
woman,  which,  when  filtered,  leaves  after  j 
evaporation    a    dry   residue   in   excess  of  i 
that    which    would    be    found    in    blood 
serum,  may  be  pronounced  upon  as  posi- 
tively ovarian.     Pus  and  blood  are  seen  , 
in    different    conditions;    in    some    cysts  j 
they   are   mixed  with    the    clearer  fluid,  | 
and   allowance   must   be   made   for   them 
in   chemical    investigations.     Among  the 
many  cysts  of  a  coinjunind  tumour,  some 
may    be    seen   with  almost    pure    serum, 
and,  after  tapping,  others  may  contain  pus 


and  offensive  gases.  Blood  often  mixes 
with  the  other  contents,  and  influences 
the  colour  as  well  as  other  qualities.  The 
yellow,  green,  brownish,  or  red  lints 
depend  upon  the  presence  of  bile  acids,  or 
the  admixture  of  blood  and  pus,  which 
may  be  recent  and  pure,  or  old  and  un- 
dergoing changes.  The  turbidity  of  the 
fluid  depends  on  the  admixture  of  these 
secondary  matters.  Blood  is  not  unfre- 
quently  effused  into  the  smaller  cysts, 
where  it  sometimes  becomes  fibrillated 
and  partially  organised,  though  it  more 
frequently  runs  into  a  state  of  decom- 
position. 

After  Scherer's  discovery  of  paral- 
bumen,  and  the  subsequent  discovery 
that  this  derivative,  or  altered  form  of 
albumen  proper,  is  a  chief  ingredient  in 
ovarian  fluids,  it  was  at  first  believed  that 
it  would  be  a  sure  means  of  distinguishing 
these  from  all  other  fluids  in  abdominal 
swellings.  But  later  experience  has 
proved  that  this  test  alone  is  unreliable. 
The  presence  of  paralbumen  is  certainly 
not  a  positive  sign  that  fluid  has  come 
from  an  ovarian  cyst.  Dr.  Schetelig 
found  the  contents  of  a  large  renal  cyst, 
which  he  had  emptied,  to  consist  mainly 
of  paralbumen  with  cholesterine,  and 
there  was  no  trace  of  urea,  the  proper 
kidney  structure  having  been  annihilated. 
But  Scherer  also  pointed  out  the  relations 
of  metalbumen  to  mucin,  which,  he  says, 
colloid  matter  always  contains  inconsider- 
able quantity  ;  and  he  raised  the  question 
whether  metalbiimen  ought  not  to  be 
considered  as  a  transition  state  between 
albumen  and  mucin  or  colloid  matter. 
Paralbumen  and  metalbumen  differ  froni 
the  true  albumen  in  that  they  are  soluble 
in  boiling  acetic  acid.  You  take  a  test 
tube  and  boil  the  ovarian  fluid ;  the  albu- 
men is  coagulated.  You  add  double  the 
volume  of  strong  acetic  acid  to  the  coagu- 
lum,  boil,  and  shalve  it;  when,  if  the 
albumen  be  true,  the  ccagulum  does  not 
redissolve  in  the  acetic  acid.  But  coagu- 
lated paralbumen  or  metalbumen  either 
dissolves  or  forms  a  whitish  transparent 
fluid,  or  breaks  up  into  a  kind  of  jelly- 
like translucent  mass  which  is  easily  dis- 
tinguishal)le  from  true  albumen  coagu- 
lated by  heat.  These  results  led  to  the 
belief  that  we  had  a  means  of  diagnosing 
abdominal  fluids;  and  it  was  said  that  if 
the  coagulated  albumen  from  them  dis- 
solved in  acetic  acid  they  were  ovarian  ; 
and  if    it   did    not  redissolve,  they  were 


DIFFERENTIAL  DIAGNOSIS   OF   OVARIAN  TUMOURS 


17 


ascitic.  That  was  frequently  right. 
Sometimes,  however,  part  woull  redis- 
solve  and  part  would  not.  Then  the 
supposition  was  that  it  was  a  mixed  fluid, 
some  ovarian  and  gome  peritoneal ;  that 
an  ovarian  cyst  had  burst  and  some  of  the 
fluid  was  in  the  peritoneal  cavity,  making 
a  combined  fluid  which  contained  some 
true  albumen  and  some  paralbumen ;  and 
this  inference  was  often  true. 

There  are  sometimes  traces  of  sugar  ; 
and  fibrinogen,  when  a  constituent,  may 
be  demonstrated  by  applying  A.  Schmidt's 
test — the  addition  o£  a  few  drops  o£  blood 
to  the  fluid.  A  distinct  clot  will  form 
with  fibrinogen  in  from  25  to  90  minutes, 
involving  the  blood  corpuscles  which  had 
been  added.  The  clot  is  generally  so  firm 
that  it  can  be  raised  unbroken,  and  if 
squeezed  in  the  hand,  a  quantity  of  fluid 
issues  out,  leaving  a  loose  bundle  of  fibril- 
lated  substance.  Klob  divided  the  con- 
tents of  an  ovarian  cyst  into  two  portions. 
Into  the  one  he  poured  a  few  drops  of 
blood,  and  at  the  end  of  three  hours  the 
whole  was  converted  into  a  mass  as  solid 
as  jelly,  while  the  other  portion  Avithout 
blood  showed  no  signs  of  coagulation,  even 
after  long  standing.  Fibrinogen,  how- 
ever, is  also  found,  according  to  Schmidt 
and  Virchow,  in  ascitic  fluid  and  other 
serous  secretions.  The  presence  of  fibrine 
was  at  one  time  regarded  as  a  proof  of  an 
abdominal  fluid  having  been  effused  from 
a  serous  membrane,  not  from  the  secretin^ 
membrane  of  an  ovarian  cyst.  And  if 
fluid  contained  both  fibrine  and  paralbu- 
men, the  supposition  was  that  an  ovarian 
cyst  had  burst  and  there  was  a  mixture 
of  two  fluids.  If  no  fibrine  could  be  de- 
tected in  the  composite  fluid  taken  from 
the  peritoneal  cavity,  then  it  Avas  supposed 
that,  instead  of  preserving  their  own 
chemical  characters  after  admixture,  the 
fibrinogenous  elements  of  the  serous  fluid 
were  acted  upon  by  the  paralbumen  of 
the  ovarian  fluid  in  such  a  way  as  to  in- 
terfere with  the  characteristic  coagulation. 

Dr.  Schetelig  informed  me  that,  in  a 
case  he  watched  at  Breslau,  the  presence 
o£  fibrine  in  the  fluid  at  the  first  tapping 
showed  that  it  was  purely  ascitic — while, 
on  the  tapping  being  repeated,  coagulation 
did  not  take  place,  and  paralbumen  was 
detected.  This  was  accounted  for  by 
rupture  of  an  ovarian  cyst  into  the  peri- 
toneal cavity,  a  supposition  which  was 
subsequently  proved  to  be  correct  at  the 
time  of  ovariotomy. 


Nor  does  the  presence  of  fibrine  prove 
that  the  fluid  is  not  ovarian,  for  in  a 
dermoid  tumour,  which  I  removed  in 
June  I8G9,  Dr.  Schetelig  m?.de  out  three 
distinct  kinds  of  fluids  in  a  number  of 
isolated  cysts.  In  some  there  was  an 
emulsion  of  fat  and  cholesterine  ;  in  others 
the  albuminoid  liquid  so  common  in 
ovarian  dropsy ;  and  thirdly,  in  different 
parts  of  the  large  tumour,  '  certain  small 
isolated  bags  full  of  a  limpid  thin  serum, 
which,  being  exposed  to  the  atmosphere, 
soon  coagulated  like  any  other  serous  fluid 
overcharged  with  fibrine.' 

The  more  consistent  colloid  substances 
are  occasionally  distributed  in  ovarian 
cysts  in  a  very  peculiar  manner.  They 
form  conical  columns  with  their  broad 
bases  directed  outwards.  Between  these 
columns,  a  whitish  or  yellowish  matter, 
consisting  of  epithelial  cells  in  a  state  of 
degeneration,  is  placed  Avithout  any  definite 
arrangement.  Such  cysts  have  probably 
been  formed  by  the  confiuence  of  several 
smaller  cysts  of  which  nothing  remains 
but  the  epithelial  investment  undergoing 
fatty  decay,  and  so  tracing  out  tlie  former 
lines  o^  separation. 

The  chemical  examination  of  colloid 
substances  and  other  fluids  from  multi- 
locular  cysts  has  given  results  of  the  most 
contradictory  kind,  as  is  seen  by  Dr. 
Mehu's  assertion,  that  he  has  never  found 
a  trace  of  mucin  in  ropy  ovarian  fluids. 
But  this  may  be  explained  by  the  suppo- 
sition that  operators  have  not  all  had  the 
same  opportunity  of  collecting  a  great 
variety  of  specimens,  and  have  not  dealt 
with  the  fluids  in  the  same  stages  of 
transformation. 

While  it  is  certain,  therefore,  that  in 
cases  of  doubtful  diagnosis  comjjlete  re- 
liance cannot  be  placed  on  the  chemical 
characters  of  fluids  removed  from  the 
abdomen,  and  that  the  rule  of  paralbumen 
being  the  characteristic  of  ovarian  fluids, 
and  fibrine  of  serous  fluids,  and  the  con- 
joint presence  of  paralbumen  and  fibrine 
pointing  to  a  mixture  of  the  two  fluids,  is 
open  to  many  exceptions — it  is  still  true 
that  the  rule  is  sufficiently  often  correct 
to  become  an  aid  of  much  value  in  arriving 
at  a  diagnosis,  and  to  encourage  us  to 
attain  more  accurate  knowledge  by  more 
extensive  observation  and  research. 

Ik  his  '  Etude  sur  lesLiquides  extraits 
des  Kystes  Ovariques,'  Dr.  Mehu  states 
that  all  his  investigations,  microscopic 
and    chemical,    Avere  made    upon   fluids 

C 


18 


OVAMAN   AND   ALLIED   TUMOURS 


drawn    from    the    living   patient — never 
'from  cysts  after  ovariotomy  or  from  the 
dead  body  : 

That,  while  he  found  the  proportion 
of  organic  matter  to  vary  from  2-50 
grammes  to  more  than  140  grammes  in 
the  kilogramme  of  filtered,  and  200 
grammes  or  more  in  the  unfiltered  ovarian 
fluids,  the  weight  of  mineral  salts  obtained 
from  the  same  quantity  was  nearly  uni- 
form, from  7  to  9  grammes,  generally 
between  8  grammes  and  8"50  grammes : 

That  he  could  almost  always  trace  the 
appearance  of  liquid  oil  to  its  use  on  the 
trocar : 

That  the  fatty  matters  found  on  the 
surface  of  the  turbid  fluids,  after  being 
heated  for  a  certain  time  and  then  cooling 
at  rest,  are  the  products  of  the  disintegra- 
tion of  the  granular  aggregations,  and 
cells  containing  translucent  granules,  often 
floating  in  the  recent  fluids  : 

That  the  aggregations  of  granular 
matter  are  simply  adherent  without  enve- 
lopes : 

That  he  considers  the  large  transparent 
cells  with  granular  contents  to  be  leuco- 
cytes enlarged,  and  not  characteristic  of 
ovarian  fluids;  as  he  had  seen  them  as 
often  in  the  fluids  of  ascites,  hydrocele, 
old  serous  cysts  and  hajmatoceles,  espe- 
cially when  the  effusion  was  of  long  date : 

That  he  discovered  cholesterine  only 
nine  times  in  115  ovarian  fluids  taken 
from  Gl  jiatients,  never  in  larger  quantity 
than  30  centigrammes  in  the  kilogramme ; 
that  even  the  small  amount  of  10  centi- 
grammes, which  was  the  most  frequent, 
gave  the  glittering  appearance  in  sunlight ; 
and  that  it  was  very  rarely  seen  in  ascitic 
fluid — only  twice  in  300  cases,  one  of 
which  had  an  ovarian  tumour,  and  the 
other  partial  peritonitis  with  Bright' s 
disease : 

That  the  absence  of  spontaneously 
coagulable  librine  is  the  only  characteristic 
which  he  has  found  distinguishing  ovarian 
fluids  from  those  of  ascites,  since  in  pure 
ascitic  fluids  after  twenty-four  hours'  rest, 
there  is  almost  ahvays  a  deposit  of  some 
centigrammes  per  kilogramme  of  fibrine 
taking  the  form  of  elastic  filaments  after 
washing,  especially  when  the  effusion  has 
been  caused  by  the  irritation  of  a  tumour  ; 
while  ovarian  fluids  never  give  a  deposit 
of  this  kind  spontanciously,  and  acetjjacid 
only  causes  the  separation  of  a  small 
quantity  of  soft  matter  not  in  any  way 
elastic : 


But  that,  in  connectloit  with  this  ob- 
servation, it  must  be  remembered  that, 
when  containing  a  large  quantity  of  leu- 
cocytes, ascitic  fluid  does  not  yield  a 
deposit  of  fibrine,  and  that  it  is  necessary 
to  make  allowance  for  the  admixture  of 
blood  in  the  ovarian  fluids  : 

That,  as  ascitic  fluids  never  contain 
more  solid  matter  than  the  serum  of  the 
blood,  any  filtered  serous  fluid  from  the 
abdominal  cavity  of  which  the  dry  residue 
weighs  more  than  70  grammes  per  kilo- 
gramme may  be  pronounced  ovarian,  and 
that  with  a  proportion  of  80  grammes  or 
more  there  can  be  no  longer  any  doubt : 

That  this  point  of  diagnosis  only 
applies  to  the  minority  of  cases,  as  the 
greater  number  of  ovarian  fluids  leave  a 
deposit  of  less  than  70  grammes  : 

That  the  only  cases  of  cure  after 
tapping  are  those  in  which  the  fluid  comes 
from  a  simple  cyst,  is  clear,  free  from 
albumen,  and  yields  a  residue  of  not  more 
than  18  grammes  to  the  kilogramme  : 

That  the  composition  of  the  fluids 
varies  very  much  in  twin  tumours,  in  the 
different  parts  of  a  multilocular  tumour, 
and  at  the  earlier  or  later  stages  of  the 
same  tapping : 

That  the  viscidity  of  the  ropy  ovarian 
fluids  is  due  to  paralbumen,  which  has 
never  yet  been  produced  separately  in  a 
pure  state ;  and  that  he  hVs  never  found 
a  trace  of  mucin  in  them.  \ 

It  is  to  be  regretted  thlit  the  service 
afforded  to  our  diagnosis  of  abdominal 
fluids  by  assisted  sight  is  uncertain. 
Microscopical  science  in  its  application 
to  medicine  requires  the  skill,  aptitude, 
and  discrimination  of  an  expert.  Obser- 
vations made  without  wide  experience, 
the  most  scrupulous  precautions,  and  an 
absolute  freedom  from  speculative  bias, 
are  misleading.  In  ordinary  practice  the 
necessary  qualifications  and  conditions 
are  rarely  at  command.  Such  Avork  as 
has  been  done  hitherto  leaves  us  without 
positive  guidance  in  forming  our  judg- 
ment, and  we  must  be  satisfied  with  a 
confirmation  of  omnions  by  the  ocular 
interpretations  of  objects  under  magnify- 
ing power. 

Long  ago  Hughes  Bennett  took  the 
investigation  of  ovarian  fluids  in  hand, 
and  he  was  i'ollowed  by  Nunn.  Both 
observed  the  same  granular  cells  and 
granular  matter  in  many  of  their  exami- 
nations, and  Drysdalo  has  done  so  too. 
Bennett  and  Drysdale  regarded  them  as 


DIFFERENTIAL   DIAGNOSIS   OF  OVARIAN  TUMOURS 


19 


diagnostic,  but  Nunn  accepts  them  as  of 
only  secondary  importance  as  a  point  of 
evidence.  Peaslee  remarked  upon  their 
frequent  absence  from  iluids  taken  from 
cysts  removed  from  the  ovary,  and 
thought  the  utmost  that  can  be  said  is 
that,  when  seen,  they  give  a  presumption 
of  ovarian  fhiid.  Tlie  later  work  of 
Foulis  and  Thornton  does  not  add  any 
greater  certainty  to  this  question.  But 
they  have  gone  a  step  further,  and 
pointed  out  that  in  cases  of  ovarian  or 
peritoneal  cancer  or  sarcoma  there  are  to 
be  found  in  the  abstracted  fluid  evidences 
in  the  shape  of  Avhat  they  call  '  charac- 
teristic groups  of  cells.'  These  they  de- 
scribe as  large  pear-shaped,  round,  or  oval 
cells  containing  a  granular  material,  with 


one  or  several  large  clear  nuclei  with 
nucleoli,  and  a  number  of  transparent 
globules  or  vacuoles.  The  cells  compos- 
ing the  groups  are  many  of  them  very- 
large,  but  the  great  variety  in  size  and 
shape  is  the  marked  feature  of  the  group. 
The  discovery  of  these  objects  ought 
no  doubt  to  put  us  on  our  guard  when 
we  have  to  deal  with  tumours  doubtfully 
malignant.  If  seen,  one  may  be  pretty 
certain  that  the  tumour  is  in  some  way 
malignant ;  or,  if  they  be  found  in  fluid 
removed  from  the  peritoneal  cavity,  pro- 
bably a  sort  of  infecting  process  has  been 
going  on  there,  from  the  rupture  of  an 
ovarian  cyst  of  a  malignant  character. 
These  cells  may  have  planted  themselves 
and  multiplied,  or  they  may  have  given  a 


taint  to  the  cells  of  the  part  and  in- 
fluenced them  to  a  malignant  form  of 
reproduction.  The  truth,  however,  really 
is  that  malignant  disease  is  a  condition  of 
degradation.  Nutrition  is  imperfect  and 
development  is  misdirected.  It  has  no 
specific  form  of  cell,  but  such  cells  as  are 
produced  in  its  growth  are  deformed,  dis- 
torted, and  early  necrosed ;  and  the 
microscopic  objects  we  find  in  general  in 
the  suspicious  ovarian  fluids  are  nothing 
more  than  groups  of  cells,  some  prolife- 
rating with  rachitic  profusion  and  mon- 
strous, others  either  dying  or  dead ;  all 
being  evidence  of  abnormally  rapid  growth, 
retrograde  change,  and  the  early  death  of 
successive  generations  of  degenerate  cells, 
the  essential  characteristics  of  malignant 
disease. 


CHRONIC    INFLAMMATION     AND    TUBERCLE    OF 
-    THE    PERITONEUM 

The  fluid  poured  out  as  the  result  of 
inflammation  of  the  peritoneum,  instead 
of  lying  free  in  the  cavity,  is  sometimes 
confined  in  pouches  formed  by  adhesions 
among  the  viscera,  or  by  false  membrane, 
or  by  attachments  of  the  omentum  or 
mesentery. 

In  his  classical  work  '  On  Diseases 
of  Women,'  West  says  :  '  One  instance 
of  this  latter  occurrence  has  come  under 
my  own  observation,  in  which  between 
four  and  five  qiiarts  of  a  dark  fluid  were 
found  collected  between  the  folds  of  the 
omentum,  and  during  the  patient's  lifetime 
frequent  discharges  of  a  similar  fluid 
had  taken  place  from  the  umbilicus.    The 


20 


OVARIAN   AND   ALLIED   TUMOURS 


dropsy  had  during  the  life  of  the  patient 
been  supposed  to  be  ovarian;  but,  though 
malignant  disease  of  both  ovaries  was 
discoverer],  yet  neither  of  them  con- 
tained fluid  at  all  similar  in  character 
to  that  which  was  found  in  the  omen- 
tum ;  nor,  indeed,  could  either  be  de- 
tected till  after  the  fluid  in  the  omental 
cyst  had  been  let  out.  I  am  aware  of 
no  means  by  which  such  cases  are  to  be 
discriminated  from  ovarian  dropsy;  as  iar 
as  I  know,  tlieir  nature  has  scarcely  ever 
been  suspected  during  the  lifetime  of  the 
patient.' 

The  fluctuation  in  such  cases,  even  if 
distinct,  is  always  limited  in  extent,  and 
confined  to  the  same  spots.  The  intes- 
tines are  found  behind  or  beside  the 
tumour,  and  do  not  as  in  ascites  rise  up 
to  the  front  of  the  abdomen,  or  vary  with 
the  position  of  the  patient.  The  appear- 
ance of  the  belly  is  flatter  than  in  cases 
of  tense  ovarian  cysts,  the  respiration  is 
less  impeded,  and  cedema  of  the  extremi- 
ties is  .seldom  seen.  Sometimes,  too,  the 
small  intestine  and  omentum  may  be 
matted  together,  and  the  way  in  which 
one  may  be  misled  under  such  circum- 
stances is  seen  by  the  following  notes 
from  my  case-book, 

February  1870. — A  lady,  aged  44, 
married  for  14  years,  was  cachectic,  pale, 
and  emaciated,  Avith  fluctuation  of  the 
abdomen  in  all  directions;  the  os  uteri 
open,  and  the  cervix  large.  By  the 
vagina,  what  was  supposed  to  be  a  cyst 
could  be  felt  behind  and  above  the 
uterus.  "Within  the  last  2  years  there 
had  been  some  increase  of  size,  but  not 
rapid  until  the  last  9  months.  Dia- 
gnosis :  ovarian  cyst,  chiefly  one  large 
cyst.  Tapjnng  was  advised,  and  17  pints 
of  fluid  were  removed,  a  good  deal  also 
being  left  behind.  On  March  17  she  was 
filling  again,  and  fluid  could  be  felt  in  the 
peritoneal  cavity.  The  uterus  was  free, 
but  the  cyst  could  not  now  be  found 
behind  it.  The  operation  for  removal  of 
the  tumour  was  done  on  March  31.  The 
whole  of  the  fluid  was  found  to  be  in 
the  peritoneal  cavity.  The  uterus  was 
roughened  on  its  peritoneal  surface,  and 
both  ovaries  felt  large,  that  on  the  left 
side  as  big  as  a  wahmf.  Above  and  to 
the  left  was  a  mass  feeling  very  like 
a  multilocular  ovarian  cyst,  evidently 
ibrmed  f)y  adhering  coils  of  intestine, 
thickened  peritoneum,  and  omentum. 
I'liere  were  no   bad  symptoms  after  the  j 


operation.  In  this  case  the  uterine  exa- 
mination and  the  moving  mass  above 
the  umbilicus  deceived  me ;  the  mass  of 
intestine  and  omentum  felt  so  very  mucli 
like  an  ovarian  cyst.  In  subsequent 
cases  percussion  has  removed  doubt. 

Two  very  similar  cases  are  recorded 
in  the  American  journals ;  one  in  which 
McDowell,  after  considering  the  dia- 
gnosis as  certain,  opened  the  abdomen 
and  found  nothing  but  a  mass  of  intes- 
tines conglomerated  by  adhesions ;  in  the 
other  the  ovaries  were  discovered  to  be 
sound,  and  the  swelling  due  to  thickened 
and  indurated  omentum. 

But  fluid  in  the  peritoneum  may  be 
associated  with  cancer  and  tubercle  of  the 
membrane,  and  give  rise  to  difficulties  in 
the  diagnosis,  as  in  the  case   of  an  un- 
married  lady,  aged  22,  whom    I  saw  in 
1862.     The  abdomen  was  as  large  as  that 
of  a  woman  near  the  full  period  of  preg- 
nancy, and  was    distended  uniformly  by 
fluid,   which   gravitated   so    decidedly    to 
the  lowest  point  with  all  changes  of  posi- 
tion,  that  it   was   evidently   free    in  the 
peritoneal    cavity ;    and    looking   to   the 
appearance  of  the  patient,  and  to  the  fact 
that  she  had  occasional   pain,  I  had  little 
doubt  as  to  the  disease  being  a  sub-acute 
form   of  tubercular    peritonitis.     With  a 
tonic     treatment     and      diuretics      there 
was  temporary  improvement.     But  some 
months  afterwards  all  the  symptoms  were 
aggravated,  and  a  remarkable  change  was 
found  to  have  taken  place.     The  abdomen 
was  much  more  prominent  or  arched  than 
before;  it  was  dull  anteriorly  in  all  posi- 
tions of  the  body,  and  clear  in  both  flanks 
as  she  lay  on   her   back.     Moreover,  on 
taking  a  deep  inspiration,  a  cyst  appeared 
to  move  downwards  from  the  epigastrium 
beneath    the   parietes.      Fluctuation  was 
evident  in  all  directions.      Tliis  led  me 
to  doubt  the  accuracy  of  my  first  opinion, 
and  she  was  tapped.      The  diagnosis  still 
remaining  uncertain,  I  made  an  explora- 
tory  incision.       No    cyst    appeared.      A 
large  quantity  of  opalescent  fluid  escaped, 
and  then  the  whole  of  the  peritoneum  was 
seen  to  be  studded  with  myriads  of  tuber- 
cles.    Some  coils  of  small  intestine  were 
floating,   but  the  great  mass   was    bound 
down  with  the  colon    and    omentum,  ail 
nodulated  by  tubercle,  towards  the  back 
and  upper  part  of   the    abdcanen.       The 
uterus  and  ovaries  were  felt  to  be  of  the 
normal  size,  but  their  peritoneal  coat  was 
very  rough.       The   patient   was   treated 


DIFFERENTIAL   DIAGNOSIS   OF  OVARIAN   TUMOUItS 


21 


precisely  as  after  ovariotomy.  She  went  abdominal  wall,  but  also  to  the  uterus 
through  rather  a  sharp  attack  of  peri-  and  sides  of  the  pelvis,  that  I  determined 
tonitis,  but  after  two  or  three  days  suf-  not  to  attempt  any  separation,  especially 
fered  hardly  more  than  from  tapping.  She  |  as  some  hardish  white  nodules  which 
passed  large  (luantities  of  urine,  and  as  it  |  were  irregularly  scattered  about  the  cyst 
f^eemed  as  if  the  use  of  the  catheter  ex-  j  walls  were  very  strongly  suggestive  of 
cited  this  diuresis,  it  Avas  continued  long  carcinoma,  and  confirmed  the  previous 
after  the  wound  had  healed.  But  the  '  suspicion  which  had  arisen  as  to  the 
most  remarkable  part  of  the  case  remains  rupture  of  a  cyst  before  the  tapping,  and 
to  be  told.  The  patient  got  well,  married,  the  diagnosis  of  malignant  disease.  The 
and  has  been  well  ever  since.  Whether  '  patient  died  about  sixty  hours  after  the 
the  peritonitis  set  up  led  to  fresh  adhe-    operation. 


Examination  showed  that  '  the  peri- 
toneum had  entirely  lost  the  character  of 
a  serous  membrane,  and  was  represented 
by  a  thick,  tough,  ash- coloured  mem- 
brane extending  all  over  the  abdominal 
cavity  and  its  contents.  It  contained 
about  two  pints  of  reddish  fluid  without 
clots.  Cancer  of  the  mesocolon  trans- 
versum,  10-12  inches  in  length  and  1 
inch  in  breadth,  extending  to  the  edge  of 


sions  or  not,  certain  it  is  that  no  more 
fluid  was  secreted.  I  heard  that  she  was 
well  in  1884. 

CANCER    OF    THE    PERITONEUM 

may  lead  to  abdominal  tumours  o£  very 
different  size  and  consistence,  and  is 
generally  accompanied  by  more  or  less 
fluid    in    the    cavity  ;    or,    as    in    a    case 

mentioned  by  Ballard,  by  an  effusion  of  the  spleen,  Avhich  is  not  involved.  Multi- 
gelatinous  matter,  with  great  elevation  of  i  locular  cyst  of  the  right  ovary,  the  size  o£ 
the  diaphragm  as  in  ascites,  dulness  on  i  a  foetal  skull.  One  cjst  showed  the  trace 
percussion  everywhere  but  at  the  epigas-  !  of  tapping  during  the  operation.  The 
trium  and  along  the  margin  of  the  ribs  on  cysts  do  not  contain  much  fluid,  but 
the  right  side,  and  fluctuation  in  every  '  mostly  cancerous  matter.  Uterus  small, 
part.  The  symptoms  produced  by  this  i  healthy,  except  one  small  point,  the  sizo 
condition  of  the  peritoneum  have  been  of  a  pea,  on  the  fundus  which  looks  white 
sometimes  so  closely  like  those  met  with  !  and  cancerous.  Cyst  of  the  left  ovary  the 
in  many  cases  of  ovarian  cysts  as  to  size  of  a  walnut;  no  cancer.' 
deceive  men  of  very   great   experience;  A  similar  case  was  that  of  a  widow, 

and  I  have  repeatedly  been  sent  for  under  I  aged  51,  who  in  July  18G8  had  a  hard 
such  circumstances  expressly  to  discuss  movable  nodule  xinder  the  right  false  ribs, 
the  question  of  ovariotomy,  when  the  '  and  a  tumour  in  the  abdomen  visibly 
patient  was  not  far  from  the  end  of  ■  movable,  without  any  evidence  of  adhe- 
her  career.     Amonc:  my.  own   cases  the    sions.    The  parietes  of  the  abdomen  were 


coexistence  of  cancer  has  been  sometimes 
so  masked  by  the  symptoms  of  ovarian 
disease  that  one  has  been  led  on  by  the 
hope  of  giving  operative  relief.  For 
instance,  in  a  case  on  which  I  operated  in 
October  1868,  the  peritoneum  exposed 
was  so  thick  that  I  doubted  whether  it 
was  the  cyst  or  not,  and  so  tapped  rather 
than  make  any  separation  of  it.  Some 
pints  of  red  serous  fluid  escaped,  and 
more  still  when  the  trocar  was  withdrawn. 
On  enlarging  the  opening  some  small 
intestines  appeared  floating  in  the  remain- 
ing fluid.  It  was  then  seen  that  a 
multilocular  cyst  had  given  way  behind, 
and  that  its  sac  formed  one  general  cavity 
with  the  peritoneum.  Below  a  lai-ge 
secondary   cyst  was  prominent.       This  I 


thin,  marked  with  numerous  linese  albi- 
cantes,  but  there  were  no  dilated  veins. 
A  wave  of  fluctuation  was  felt  over  the 
surface  of  the  tumour,  and  the  sounds  on 
percussion  were  clear  two  inches  above 
the  umbilicus,  dull  in  the  lumbar  region. 
The  tumour  could  be  felt  in  front  of  the 
uterus,  and  through  the  rectum.  It  began 
to  form  about  twelve  years  before,  but 
caused  no  inconvenience  for  six  years. 
It  then  grew  rapidly,  filling  the  abdomen, 
without  much  pain.  The  size  had  much 
augmented  of  late.  The  patient  was  twice 
tapped,  about  12  pints  of  clear  and  slightly 
coagulable  fluid  being  drawn  off  from  the 
peritoneum  each  time. 

On  August  3,  a  tentative  incision  was 
made.      A  white  c:listening  tumour  was 


tapped  and  emptied,  and  then  found  the  exposed  on  dividing  the  peritoneum.  A 
whole  of  the  outer  coat  of  the  large  cyst  I  few  pints  of  clear  fluid  escaped,  and  I  then 
so  intimately  adherent  not  only   to   the  [  felt  the  movable  nodule  under  the  right 


99 


OVARIAN   AND   ALLIED   TUMOURS 


false  ribs  to  be  apparently  a  lump  of 
cancer  in  the  abdominal  wall.  The  uterus 
and  ovaries  seemed  to  be  fused  together, 
the  intestines  adhering  behind ;  there 
■were  also  some  slight  but  vascular  parietal 
adhesions.  The  patient  died  about  ten 
days  after  the  operation.  There  Avere 
three  or  four  pints  of  serum  in  the  peri- 
toneal cavity,  and  adhesions  of  the 
omentum  and  transverse  colon  to  the 
upper  part  of  the  tumour.  A  hard  white 
nodvile  as  large  as  a  Avalnut,  in  the 
abdominal  wall  below  the  right  false  rib, 
was  found  to  consist  of  fibrillated  con- 
nective tissue,  with  large  oblong  nucleated 
cells  in  an  advanced  stage  of  fatty  de- 
generation. Both  ovaries  were  fused 
together,  and  formed  one  tumour ;  a 
sebaceous  and  piliferous  cj'st  was  formed 
exclusively  by  the  left  ovary,  and  the  rest 
of  the  tumour  by  the  right. 

In  all  such  cases  suspicion  of  their 
real  nature  should  be  aroused  if  a  patient 
has  either  a  very  thin  and  tense,  or  an 
oedematous  abdominal  wall,  anasarca  of 
the  lower  limbs,  general  emaciation,  a 
cachectic  aspect,  free  fluid  in  the  peritoneal 
cavity,  and  especially  so  if  the  loss  of 
flesh  and  amount  of  pain  are  more  rapid 
and  severe  than  an  ovarian  or  other 
innocent  tumour  would  account  for. 

TYMl'ANITKS    AND    rHAKTOM    TUMOUItS 

Tympanitic  distension  of  the  abdomen 
may  give  rise  to  some  aAvkward  questions; 
but  it  is  difficvilt  to  believe  that  any  sur- 
geon of  reasonable  experience  could  be  so 
deluded  by  such  a  condition  as  to  think 
that  he  had  before  him  a  case  of  ova- 
rian tumour,  and  attempt  the  operation 
of  ovariotomy.  Yet  Simpson  says  that  it 
has  happened  no  less  than  six  times,  and 
Bright  published  the  case  of  a  woman 
who  entered  Guy's  Hospital  with  an 
unhealed  incision  in  the  middle  line  of 
the  abdomen  said  to  have  been  made  by 
a  surgeon  for  removal  of  a  tumour.  She 
had  distension  of  the  abdomen,  with  a 
variety  of  hysterical  symptoms,  and  was 
recognised  as  having  been  formerly  under 
the  care  of  Dr.  Marcet  for  the  same  con- 
dition. Thoiigli  the  abdomen  bore  a  very 
peculiar  appearance,  strongly  resembling 
an  encysted  tunionr,  the  geiKTal  symptoms 
were  so  marked  that  a  little  observation 
was  sufficient  to  convince  any  experienced 
person  f<f  the  real  character  of  the  disease. 

Boinet  relates  also  that   a  miserable 


woman  of  weak  intellect,  tympanitic  and 
impressed  Avith  the  notion  that  she  had 
an  abdominal  tumour,  was  unfortunate 
enough  to  meet  with  two  or  three  surgeons 
Avho  persuaded  themselves  that  she  had 
ovarian  disease,  and  gave  way  to  her  im- 
portunate demands  for  an  operation.  Their 
rash  gastrotomy  only  showed  the  existence 
of  cancer,  and  killed  the  woman. 

These  hysterical  distensions  of  the 
abdomen  present  themselves  in  a  variety 
of  forms.  Sometimes  the  belly  is  uni- 
formly bloAvn  up  to  the  size  of  advanced 
pregnancy,  and  is  rounded,  hard,  and  re- 
sistant. The  hand  makes  no  impression 
on  it,  and  change  of  position  causes  no 
alteration  in  shape.  But  there  is  no 
fluctuation — the  resonance  is  universal, 
hysterical  symptoms  are  generally  present; 
and,  under  the  influence  of  chloroform, 
the  swelling  entirely  disappears,  leaving 
the  abdomen  flaccid,  and  allowing  the 
hand  to  rest  upon  the  bones  of  the  spine. 
In  other  cases  the  distensions  are  local, 
and  it  is  noticed  that  they  occur  more 
often  on  the  right  side.  Portions  of  the 
abdominal  Avail  are  gathered  up  into  rigid 
knobs,  which  remain  so  long  unaltered 
as  to  simulate  an  internal  tumour,  espe- 
cially as  they  are  sometimes  situated  over 
accumulations  of  hardened  faeces,  and  are 
accompanied  by  a  good  deal  of  tenderness 
of  the  parts.  Careful  and  patient  palpa- 
tion, purgatives,  and  chloroform  Avill 
generally  lead  to  a  solution  of  the  mys- 
tery ;  or  may  eA^en  disclose  the  existence 
of  an  unsuspected  ovarian  tumour,  Avhich, 
by  its  presence  in  the  pelvis,  had  given 
rise  to  the  train  of  hysterical  symptoms, 
and,  among  others,  to  the  swelling,  appa- 
rently the  most  important  matter  calling 
for  treatment. 

The  flrst  draAving  on  the  next  page, 
from  a  photograph,  shoAvs  hoAV  very  accu- 
rately one  of  these  phantom  tumours,  or 
the  condition  Avhich  I  have  now  been  de- 
scribing as  hysteric  tympanites,  may  re- 
semble a  uterine  or  ovarian  tumour.  The 
loAver  part  of  the  abdomen  arches  forAvard 
exactly  as  in  pregnancy,  or  as  with  an  ova- 
rian tumour  of  moderate  size  Avhen  the  ab- 
dominal Avail  is  not  lax  ;  and  the  Avail  is 
so  tense,  the  patient  so  i-esists  pressure,  or 
complains  so  much  of  tenderness  on  pres- 
sure, and  the  abdominal  muscles  contract 
so  spasmodically  and  irregularly,  that  it 
is  by  no  means  difficult  to  fancy  that  a 
tumoiu",  or  even  the  movements  ofafoRtus, 
may  be  felt.     The  girl  Avhose  portrait  is 


DIFFERENTIAL   DIAGNOSIS   OF   OVARIAN   TUMOUltS 
here  given  was  in  the  Samaritan  Hospital  j  The  arched  abdomen  is  seen  to  have  been 

£ —  ^ 4-Z — «    — -1  ; *. A:ixi  —  It  *„    „^*,     I  f^i-,\i-n  /l^+4-,^«^^l     ^-^A  It-  , ...1 ^1   _ 


for  some  time,  and  it  was  difficult  to  con 
vince  her,  her   friends,    and  even    some 


medical  friends  who  saw  her  with  me, 
that  she  had  no  abdominal  tumonr.  The 
tympanitic  resonance  on  percussion  was, 
of  course,  the  leading  element  in  the 
diagnosis ;  but  the  most  conclusive  test 
was  the  comj^lete  subsidence  of  the  swell- 
ing and-  the  flattening  of  the  abdomen 
when  the  girl  was  fully  under  the  influence 


quite  flattened,  and  it  was  easy  when  the 
abdominal  walls  were  so  flaccid,  to  fieel 
tlie  pulsations  of  the  aorta,  the  vertebral 
column,  the  brim  of  the  pelvis,  and  to 
become  certain  that  there  was  no  abdomi- 
nal nor  pelvic  cyst  of  any  kind.  Yet  the 
instant  the  effect  of  the  chloroform  began 
to  pass  away  the  tumour  always  began  to 
reappear.  This  was  shown  several  times 
when  the  experiment  was  tried,  and  on 
one  occasion  a  photograph  was  taken 
when  she  was  nearly  awake,  and  the 
tumour  was  almost  as  prominent  as  in  her 
ordmary  condition,  shown  in  the  first 
drawing.  She  was  an  hysterical  girl,  but 
there  was  no  voluntary  or  conscious  impo- 
sition on  her  part  so  far  as  I  could  ascer- 
tain. She  improved  under  a  course  of 
purgatives  and  steel,  but  I  have  not  seen 


of  chloroform.  The  photograph  from 
which  the  second  drawing  was  made  was 
taken  while  she  was  completely  narcotised. 


her  since  she  loft  the  hospital.  In  one 
woman  the  abdominal  wall  thus  expanded 
gave  rise  to  a  suspicion  of  double  ovarian 
cyst.  The  recti  muscles  formed  a  distinct 
line  of  demarcation  between  two  protu- 
berances. The  supposed  tumour  seemed 
to  be  Avell  defined,  but  the  belly  resumed 
its  natural  shape  under  chloroform. 

In  1872  a  woman  was  sent  to  the 
Samaritan  Hospital,  supposed  to  be  suffer- 
ing from  a  large  ovarian  tumour.  The 
tympanitic  resonance,  Avith  the  absence  of 
fluctuation,  at  once  showed  that  there 
could  be  no  large  abdominal  tumour,  but 
some  hardness  above  the  pitbes  led  to  a 
vaginal  examination,  when  an  early  preg- 
nancy Avas  detected.  On  administering 
chloroform  the  distended  abdomen  at  once 
flattened  down,  and  the  outline  of  the  en- 
lar2;ed  uterus  could  be  distinctly  traced. 


24 


OVATUAN   AND   AIXIED   TUMOURS 


This  is  the  only  case  in  which  I  have  seen 
tympanites  occur  in  a  pregnant  woman. 
I  have,  however,  several  times  seen  it 
accompany  small  fibroid  tumours  of  the 
uterus,  uterine  polypi,  uterine  displace- 
ments, and  small  ovarian  tumours  which 
have  not  risen  out  of  the  pelvis.  Once 
only  have  I  met  with  this  voluminous 
turgidiry  in  a  man,  and  wilh  him  I  had 
no  difficulty.  He  was  one  of  the  Crimean 
invalids,  and  came  into  my  hands  at 
Smyrna. 

FIBRO-PLASTIC  AND  FATTY  TUMOURS  OF 
PERITONEUM,  I'MENTUM,  AND  SUB-PERI- 
TONEAL   CELLULAR    TISSUE 

The  symptoms  caused  by  the  groAvth 
of  large  fatty  and  fibro-plastic  tumours 
from  various  parts  of  the  peritoneum  or 
mesentery  so  much  resemble  those  of  true 
ovarian  disease,  that  their  real  nature  can 
only  be  determined  in  some  cases  by 
an  exploratory  incision  or  tapping.  The 
difficulties  and  dangers  attending  the.^e 
obscure  diseases  are  exemplified  in  the 
histories  of  the  cases  which  now  follow. 

In  1867  I  operated  on  a  lady  aged  40, 
who  for  many  years  had  been  suffering 
from  an  abdominal  tumour  about  the 
nature  of  which  various  opinions  Avere 
entertained.  IVIy  first  incision  was  ex- 
ploratory, and  showed  that  the  tumour 
was  a  mass  of  fat.  It  was  then  arranged 
that  an  attempt  should  be  made  to  remove 
the  tumour.  This  Avas  done,  and  lobulated 
Uiasses  of  fat,  weighing  20  pounds, 
Avere  extracted  after  dividing  a  loose 
cellular  capsule.  A  large  lobule  felt  in 
the  neighbourhood  of  the  right  kidney 
Avas  not  disturbed.  The  tumour  appeared 
to  have  originated  in  the  mesentery.  Some 
of  the  lobules  Avere  evidently  appendices 
epiploic^  enormously  hypertrophied. 

The  patient  died  58  hours  after 
the  operation.  The  mass  of  fat  left;  on 
the  right  side  involved  the  right  kidney, 
pushed  the  ascending  colon  over  to  the 
left,  and  adhered  to  the  imder  surface  of 
the  liver.  INIany  mesenteric  glands  Avere 
enlarged  and  enveloped  in  lat.  There 
was  not  more  fat  than  usual  in  the  omen- 
tum. The  Aveight  of  the  ])ortion  of  fatty 
tumour  not  removed  during  life  Avas 
estimated  at  10  or  12  pounds.  The 
uterus  and  both  ovaries  Avere  liealth}'. 

Mr.  Coo])er  Forster,  in  the  '  Patho- 
logical Transactions,'  records  another  case 
of   fibro-fatty    tumour   of  the  abdomen, 


weighing  55  pounds.  In  the  greater 
part  of  the  tumour  fat- cells  with  the  usual 
connective  filaments  and  vessels  made  up 
the  tissue— histologically  perfect  fat. 

A  Avoman,  aged  2G,  after  her  confine- 
ment in  18G7,  felt  a  small  lump  in  the 
right  iliac  region.  This  increased  very 
slowly  ixntil  May  1869.  After  May 
the  growth  Avas  rapid.  On  February  23,. 
]870,  an  exploratory  incision  was  made. 
On  exposing  the  peritoneum  1  perceived 
that  the  tumour  Avas  an  extremely  Avascular, 
soft,  friable,  granular  mass,  and  satisfied 
myself  by  stopping  the  bleeding,  Avhich 
Avas  rather  free,  both  from  arteries  and 
A'eins.  She  died  March  3,  and  on 
examining  the  body  I  found  the  tumour 
to  be  firmly  adherent  to  the  abdominal 
wall,  to  the  liver  and  intestines,  and  to  the 
uterus  behind ;  but  both  uterus  and 
ovaries  Avere  free  from  disease.  In  some 
parts  there  Avere  detached  bodies  like  large 
appendices  epiploicse,  and  from  some  of 
the  intestines  there  Avere  cyst-like  groAvths. 
Dr.  Wilson  Fox  reported  that  the  masses, 
and  groAvths  on  the  intestines,  appeared 
to  be  of  a  doubtfully  malignant  nature, 
but  that  he  found  no  secondary  implica- 
tion of  other  organs. 

In  the  '  Archives  of  Pathological 
Anatomy'  (Bd.  63,  No.  4)  VirchoAV 
describes  a  retro-peritoneal  tumour,  which 
I  had  removed  from  a  lady  in  Pomerania, 
in  May  1875,  and  left  with  him  for  exa- 
mination on  my  return  througli  Berlin,  as 
a  '  fibroma  molluscum  cysticum  abdomi- 
nale.'  The  patient  Avas  a  Avidow,  40  years- 
of  age.  She  had  been  tapped,  and  a  large 
amount  of  pus  Avithout  odour  came  away. 
Finding  on  my  arrival  a  A-ery  large  ab- 
dominal tumour  only  centrally  fluctuating, 
and  pressing  the  perineum  and  posterior 
vaginal  Avail  far  doAvn  betAveen  the  thighs 
so  that  I  could  not  ascertain  the  state  of 
the  uterus,  I  Avas  in  great  doubt  as  to  the 
nature  of  the  case,  but  at  once  commenced 
an  exploratory  operation.  After  dividing 
the  abdominal  wall  to  the  extent  of  five 
inches  betAveen  the  umbilicus  and  pubes,. 
some  loose  fat  Avas  seen  Avith  very  large 
veins.  Carrying  on  the  incision  it  passed! 
into  the  substance  of  a  solid  tumour 
aj)parently  glandular  or  fibro-plastic ;  ancJ 
on  pushing  one  finger  onAvards,  a  cavity 
Avas  opened  from  Avhich  some  15  to  20 
pints  of  pus  escaped  Avith  masses  of 
yelloAvish  Avhite  curd-like  substance.  By 
;  draAving  the  back  part  of  this  cavity 
I  forAvards,    thus   inverting  it   and  pulling 


DIFFERENTIAL   DIAGNOSIS   OF   OVARIAN   TUMOURS 


ZJ 


upon  it,  a  large  solid  mass  was  withdrawn. 
It  had  lain  behind  and  to  the  right  side  of 
the  uterus  in  the  loose  cellular  tissue  of 
the  pelvis.     Its  connection  with    the  left 
side  of  the  uterus  behind  was  first  tied  and 
divided,  without  interlisrence  with  the  left 
ovary  or  tube.     A  similar  connection  on 
the  right  side   was  secured  by  transfixion 
and  ligature.     The  quantity  of  fluid   re- 
moved was  7  litres,  the   .solid  matter  10^  i 
pounds,  or  about  25  pounds  in  all.     I  left  I 
the  lady  next  day  going  on  well,  and  with  I 
the    exception  of  some  bladder  trouble,  ! 
recovery  may  be  said  to  have  been  unin-  i 
terrupted.     I  heard  of  her  in  1884  as  in  ; 
excellent  health.  j 

Virchow  speaks  of  this  fibroma- 
molluscum  as  a  common  formation  in  the 
cellular  tissue  of  the  pelvis ;  but  in  my 
experience  tumours  of  such  character 
attaining  a  size  calling  for  surgical  treat- 
ment are  extremely  rare. 

Tumours  described  as  sub-peritoneal, 
myxoma-lipoma todes,  or  lipoma-myxoma- 
todes,  have  been  observed  in  tlie  sub- 
peritoneal tissues  and  in  the  mesentery 
and  cases  have  been  recorded  in  Avhich, 
after  removal  of  the  abdominal  tumoiir, 
secondary  formations  of  similar  structure 
liave  taken  place  in  the  neighbouring 
glands,  or  in  other  organs  such  as  the 
lungs  or  liver. 

HYDATIDS 

Hydatids  growing  from  some  part  of 
the  peritoneal  sxnface  often  acquire  an 
enormous  bulk,  and  distend  the  abdominal 
walls  in  proportion.  The  displacement  of 
the  viscera,  the  encroachment  on  the 
thoracic  region,  and  the  coincident  inter- 
ference with  the  action  of  the  heart  and 
lungs,  are  as  marked  as  in  advanced  cases 
of  ovarian  disease.  But  the  history  of  a 
case  of  hydatids  Avill  commonly  show  that 
the  dilatation  commenced  in  the  upper 
part  of  the  abdomen,  extended  next  to 
the  hypochondria,  and,  lastly,  to  the  pel- 
vic region.  The  growth  of  hydatids  is 
more  rapid  than  that  of  ovarian  cysts. 
There  may  be  similar  irregularities  of 
surface  and  contour  felt  by  pressure,  but 
the  interspaces  or  depre^isions  between  the 
projecting  masses  will  be  more  distinguish- 
able in  hydatid  disease ;  and  are  sometimes 
marked  by  distinct  resonance,  when  por- 
tions of  distended  intestine  happen  to  be 
lying  amid  them.  The  abdominal  reso- 
nance is  more  lateral  in  hydatid  disease 


than  in  cases  of  ovarian  tumour,  but  in 
both  cases  will  be  limited  to  the  part  in 
which  the  bowels  are  pent  up.  The 
fluctuation  in  hydatids  is  obscure  and 
circumscribed ;  but  when  it  can  be  felt 
the  hydatid  fremitus  is  decisive.  It 
must  after  all  be  remembered  that  hy- 
datids may  originate  in  any  part  of  the 
peritoneum,  and  when  they  happen  to  do- 
so  in  the  region  of  the  broad  ligament  th& 
diagnosis  will  demand  additional  circum- 
spection. 

The  best-marked  case  of  hydatids 
of  the  peritoneum,  as  distinguished  from 
hydatid  cysts  of  the  liver,  which  I  have 
seen,  was  a  woman  who  was  in  the  Sama- 
ritan Hospital  in  1870-1.  The  appear- 
ance of  her  abdomen  is  well  shown  in  the 


drawing,  copied  from  a  photograph  taken 
after  her  admission  to  the  hospital. 

The  abdomen  had  all  the  appearance 
of  a  case  of  multilocular  ovarian  cyst. 
Fluctuation  was  very  distinct,  but  the 
chief  peculiarity  of  the  case  was  the  exist- 
ence of  numerous  hard  nodules  scattered 
over  the  abdominal  wall.  Some  of  the 
best  marked  of  these  arc  shown  on  the 
drawing  near  the  umbilicus.  They  were 
quite  hard,  and  suggested  the  belief  that 
they  might  be  nodules  of  hard  cancer. 
Some  of  them  being  semi-resonant  gave 
rise  to  the  fear  that  they  might  be  formed 
on  the  coat  of  intestine  ;  but  the  fact  that 
the  disease  was  of  about  twelve  years'  du- 
ration, that  the  patient  had  borne  healthy 
children  during  its  progress,  that  she  was 
not  much  emaciated,  did  not  suffer  from 


26 


OVARIAN   AND   ALLIED   TUMOURS 


sickness   or    diarrhcea,    nor    from   much 
abdominal    pain  nor  tenderness,   showed 
that  cancer  might  be  almost  certainly  ex- 
cluded from   the   diagnosis,   even   before 
hydatid  fremitus  was  noticed.      This  was 
most  distinct,  and  the  diagnosis  was  com- 
'~M       plots'!  by  the  puncture,  with  a  fine  trocar, 
,!^-  r-  of  one  of  the  nodules  felt  in  the  abdomi- 
g^^t^  nal  wall.     A  little  clear  fluid  escaped,  in 
»/|;^|(^hich   the    booklets  of  the  echinococcus 
were  distinctly   seen.      No   very  urgent 
symptoms  being  present  nothing  more  was 
then  done.      I   afterwards   operated   and 
removed   3    or    4    pounds    of   hydatids. 
Considerable   relief  was   given,    but   the 
woman  died  at  the  end  of  a  few  months. 

In  another  woman,  thin,  anjemic,  and 
of  consumptive  parentage,  sent  to  the 
hospital  as  a  case  of  ovarian  disease,  I 
found  the  abdomen  distended,  tender  and 
fluctuating,  the  uterus  small  and  mobile, 
pressed  forwards  above  the  pubes,  and 
Douglas's  space  occupied  by  an  elastic 
tuuiour.  I  made  an  exploratory  incision, 
opened  a  cavity,  and  let  out  some  pints 
of  fetid  pus.  Then  several  small  cysts 
attached  to  the  omentum  and  mesentery 
Avere  removed,  and  a  larger  cavity,  corre- 
sponding with  Douglas's  space,  was  dis- 
covered and  more  pus  evacuated.  After 
■death  it  was  seen  that  the  intestines, 
omentum,  and  other  viscera  were  matted 
together  and  formed  a  sac  containing  thin 
purulent  fluid,  while  the  liver  and  spleen 
were  filled  with  hydatids.  There  Avas  a 
small  cyst  in  the  broad  ligament  on  the 
right  side  by  which  the  uterus  was  drawn 
up  in  that  direction,  and  on  the  left  side 
the  ovary  was  masked  and  the  pelvis 
blocked  up  by  numerous  small  cysts  filled 
with  hard,  gristly,  calcareous  substance 
evidently  of  hydatid  origin. 

Large  hydatid  cysts  of  the  liver  ex- 
tending low  down  in  the  abdomen,  or  even 
into  the  pelvis,  have  frequently  been  mis- 
taken for  ovarian  cysts.  In  one  such  case, 
a  young  lady  who  was  sent  to  me  by  Sir 
James  Clark,  I  Avas  able,  Avith  the  assist- 
ance of  Sir  AVilliam  Jenner,  to  make  an 
accurate  diagnosis,  and  removed  64  ounces 
of  clear  fluid  from  an  hydatid  cyst  Avhich 
projected  doAVUAvards  from  tlie  liver.  Two 
years  elapsed  before  any  of  this  fluid  re- 
collected. I  then  tapped  again,  and  found 
only  nine  ounces  in  the  cyst,  the  patient 
being  apparently  Avell  some  fcAV  months 
afterwards.  In  two  similar  cases,  in 
the  Samaritan  Hospital,  emptying  hydatid 
cysts  of  the  liver  by  tapping,  assisted  by 


an  exhausting  syringe.  Las  been  followed 
by  what  we  may  confidently  hope  is  a 
permanent  cure.  In  another  case,  after 
tapping,  the  cyst  suppurated,  its  contents 
decomposed,  the  cyst  became  distended 
Avith  gas,  and  I  inserted  a  drainage  tube. 
Daily  injections  of  iodine  solution  Avere 
used,  and  the  patient  completely  re- 
covered. Cases  have  been  recorded 
Avhere  the  cyst,  before  draining,  Avas 
stitched  to  the  abdominal  AA'all,  but  I 
have  not  yet  done  this.-^ 

Such  cases  are  not  likely  to  be  mis- 
taken for  ovarian  cysts  by  anyone  con- 
versant with  the  signs  of  hydatid  diseases 
of  the  liver,  so  Avell  described  by  Frerichs 
and  Murchison.  The  freedom  of  the 
pelvis  and  hypogastric  region  from  the 
presence  of  a  cyst,  and  the  limitation  of 
the  first  evidences  of  disease  to  the  upper 
part  of  the  abdomen,  are  the  main  points 
of  distinction.  I  have  never  seen  a  case 
of  hydatids  in  the  substance  of  the  ovary, 
and  it  is  curious  that  these  organs  seem 
to  be  aA'oided  as  the  seat  of  parasitic  life ; 
for  it  is  probable  that  in  the  reported 
cases  it  Avas  only  by  superficial  attach- 
ment to  the  peritoneal  covering  that  the 
hydatids  had  any  relation  to  the  ovary. 

PlIEGNANCY    AND    DISTENDED    UTEKUS 

Certainly  the  most  common  mistakes 
in  diagnosis  occur  AA'hen  the  uterus  is  en- 
larged from  some  cause  ;  and  pregnancy  is 
the  most  common  of  all  causes  of  enlarge- 
ment of  the  uterus.  Circumscribed  enlarge- 
ment beginning  and  going  on  Avithout  other 
marked  signs  of  pregnancy  leads  to  the 
suspicion  of  cystic  groAvth,  and  to  tiu-n 
this  into  conviction  we  have  to  consider  the 
age  of  the  patient,  certain  malformations  of 
the  genital  organs,  the  state  of  the  general 
health,  some  functional  irregularities,  the 
progress  of  groAvth,  the  configuration  of 
the  abdomen,  the  results  of  percussion 
and  auscultation,  and  the  manual  exami- 
nation of  the  uterus.  Certain  limits  of 
age  negative  the  possibility  of  conception, 
although  instances  are  recorded  where 
girls  between  12  and  15  and  women  up 
to  GO  have  borne  children.  Still,  the 
limits  of  15  and  45  are  very  rarely 
passed.  So  that  in  patients  very  young 
or  very  old  the  presumption  must  be  that 
a  voluminous  abdomen  is  the  seat  of  dis- 
ease. Again,  some  malformations  of  the 
generative  organs  render  pregnancy  im- 
possible; but   it  must  not   be  forgotten 


DIFFERENTIAL  DIAGNOSIS   OF  OVARIAN  TUMOURS 


;7 


that  impregnation  has  been  effected 
where  penetration  of  the  vagina  by  any 
solid  body  was  impossible  ;  and  in  spite 
of  procidentia  of  the  uterus,  and  of  such 
diseases  of  the  vagina  and  uterus  (vesico- 
vaginal fistula  or  uterine  cancer,  for 
example)  as  might  appear  quite  incon- 
sistent with  sexual  intercourse. 

Then  the  size  and  position  of  the 
swelling  and  the  duration  of  its  growth 
taken  together  will  influence  the  diagnosis. 
A  tumour  of  nine  months'  certain  dura- 
tion, yet  no  larger  than  a  uterus  at  tlie 
fourth  or  fifth  month,  or  one  of  only  four 
or  five  months'  standing  as  large  as  the 
uterus  at  the  close  of  pregnancy,  will  not 
be  attributed  only  to  foctation.  In  the 
case  of  a  tumour  the  history  is  Irequently 
that  of  its  discovery  on  one  side,  and  its 
advance  is  more  or  less  regular  according 
to  its  nature,  while  examples  of  the  dis- 
placement of  the  early  gravid  uterus  are 
exceptional. 

It  will  be  found  in  the  majority  of 
cases  of  tumour  which  have  lasted  long 
enough,  and  become  large  enough  to 
simulate  pregnancy,  that  instead  of  the 
ordinary  sympathetic  disturbance  of  the 
functions,  the  health  of  the  patient  has 
materially  given  way,  especially  if  the 
disease  be  assuming  a  malignant  form ; 
and  that  owing  to  the  comparative  fixity 
of  its  base  of  attachment,  and  from  the 
want  of  that  mutual  adjustment  of  parts 
which  mitigates  the  miseries  caused  by  the 
distending  titerus,  more  than  the  natural 
amount  of  discomfort  and  pain  is  encoun- 
tered. By  itself,  the  absence  or  excess  of 
the  menstrual  flow  decides  little,  and  the 
gastric,  mammary,  and  nervous  symptoms 
of  pregnancy  may  also  be  set  up  by  sym- 
pathy with  the  ovarian  irritation.  In  a 
case  where  the  question  is  between  preg- 
nancy and  ovarian  disease,  there  is  hardly 
time  for  the  modelling  oiit  of  the  peculiar 
facies  ovariana,  and  no  one  general  sym- 
ptom can  by  itself  be  taken  as  conclusive  ; 
though  in  most  of  these  consultations  the 
first  observation  of  a  patient  gives  to  an 
experienced  eye  a  right  impression  as  to 
the  real  state  of  matters. 

It  is  very  seldom  that  a  growing  ova- 
rian cyst,  even  when  unilocular,  will  leave 
the  symmetry  of  the  abdomen  unaltered. 
The  compound  and  dermoid  forms  are 
almost  invariably  lobulated,  and  give  rise 
to  unseemly  irregularity  and  distortion 
of  the  contour,  and  a  great  difference  in 
the  radiating  measurements  from  the  um- 


bilicus. The  pointing  or  flattening  of 
the  umbilicus  tells  nothing  as  to  mere 
growth,  but  whenever  the  prominence  is 
considerable,  the  ring  open,  the  skin  thin 
and  distended,  there  is  almost  always  fluid 
free  in  the  peritoneal  cavity,  and  any 
tumour  is  to  be  otherAvise  recognised. 

The  superficial  veins  of  the  abdominal 
wall  are  seldom  so  much  distended  in 
pregnancy  as  they  often  are  with  large 
ovarian  tumours :  but  linear  albicantes  are 
more  common  in  pregnancy.  They  are 
seen,  however,  over  all  large  tumours  of 
rapid  growth.  When  recent  they  are  of 
a  dark  purplish  colour;  when  old  they  are 
white,  glistening,  or  silvery.  When  the 
abdominal  Avail  is  osdematous,  the  lines) 
become  very  prominent.  This  appear- 
ance, common  in  large  solid  or  semi- 
solid abdominal  tumours,  is  rare  in  preg- 
nancy. 

It  is  only  when  the  abdominal  wall  is 
very  thick,  or  the  foetus  misplaced  or  dead, 
that  the  heart  sounds  cannot  be  heard 
after  the  sixth  month.  Sometimes  they 
are  masked  by  the  placental  murmur,  a 
blowing  sound,  synchronous  with  the  beat 
of  the  maternal  heart,  rarely  absent  in 
pregnancy,  but  very  similar  to  a  sound 
common  in  large  fibroids  of  the  uterus, 
but  very  rarely  perceptible  in  ovarian 
tumours.  The  aortic  sound  and  impulse 
of  the  mother,  being  perceptible  both  in 
pregnancy  and  in  many  uterine  and  ova- 
rian tumours,  are  of  very  little  diagnostic 
value. 

Up  to  the  fifth  month  the  pregnant 
uterus  gives  no  sense  of  fluctuation  ;  it 
has  rather  the  consistence  of  a  glandular 
or  fatty  tumour.  After  the  fifth  month  the 
sensation  conveyed  to  the  finger  is  that  of 
displacement  of  fluid,  allowing  a  hard  body 
to  be  felt.  This  is  the  fcetus,  which  from 
the  sixth  to  the  ninth  lunar  month  may 
be  pushed  from  side  to  side.  After  the 
seventh  month  it  is  often  possible  to  trace 
the  general  oixtline  of  the  foetus  so  clearly 
that  no  mistake  can  be  made.  But  Avhen 
the  abdominal  wall  is  thick,  some  of  the 
more  solid  varieties  of  ovarian  tumour 
may  very  closely  resemble  the  shape  of  a 
foetus.  An  ovarian  tumour  surrounded 
by  ascitic  fluid,  or  a  mass  of  small  cysts 
projecting  into  a  large  one,  may  be  moved 
very  much  like  a  child  in  the  liquor 
amnii.  But  the  independent  movements 
of  the  foetus  are  very  characteristic,  and, 
if  felt,  conclusive.  Sometimes,  however, 
Avith  a  livino:  child  these  movements  can- 


28 


OVARIAN    AXD   ALLIED   TUMOURS 


not  be  felt;  and  if  the  child  is  dead,  of 
course  they  cannot  be  made. 

There  are  no  ovarian  tumours  which 
give  exactly  the  same  sensation  as  the 
ballottemeiit  of  the  fatus  in  utero,  though 
internal  like  external  ballottement  may 
be  simulated  by  a  hard  tumour  floating 
in  ascitic  fluid,  or  by  a  large  cyst  con- 
taining internal  projections.  The  move- 
ments of  a  cyst  with  a  long  pedicle  could 
hardly  be  mistaken  for  those  of  the 
uterus,  as  the  corresponding  vaginal  touch 
will  indicate  its  independence.  The  effect 
which  tumours  mechanically  make  upon 
the  position  and  form  of  the  uterus  does 
not  much  resemble  that  of  pregnancy, 
and  with  the  usually  open  state  of  the  os 
in  ovarian  disease,  nothing  can  invalidate 
the  evidence  of  the  sound.  And  as  in  a 
case  of  disputed  pregnancy  the  symptoms 
can  rarely  be  so  urgent  as  to  require  im- 
mediate operation,  the  best  policy  is  tOAvaic. 

Happily,  cases  of  malplaced  fetation 
are  comparatively  unfrequent.  It  is  not 
clear  which  is  the  most  common  point  of 
attachment  of  the  errant  ovum.  During 
the  life  of  the  patient,  it  is  admittedly 
almost  impossible  to  determine  in  what 
part  of  the  genital  tract  or  abdomen  the 
ovum  is  being  developed.  Hecker  states 
that  these  pregnancies  are  mostly  abdomi- 
nal ;  Parry,  that  he  finds  the  greater 
number  recorded  as  tubal.  Wherever 
they  may  Ije,  and  however  much  they 
may  physically  resemble  an  incipient 
ovarian  cyst,  the  early  diagnosis  will 
very  much  depend  upon  the  indications 
of  conception.  These  are  absent  in  the 
case  of  ovarian  disease,  and  there  are  not 
the  distressing  symptoms,  such  as  hypo- 
gastric colicky  pains,  vaginal  htemor- 
rhages,  with  sometimes  discharge  of 
decidua,  which  accompany  these  irregular 
fcctations.  Nor  do  we  meet  with  the 
curious  moral  condition  in  which  the 
woman  persistently  believes  herself  en- 
ceinte. Too  often  the  diagnostic  problem 
finds  its  solution  in  the  early  death  of 
the  subject.  If  the  patient  should 
survive  the  third  or  fourth  month,  the 
probability  is  that  the  gestation  is  abdo- 
minal. Seventy-six  out  of  132  cases 
noted  by  Hecker  escaped.  The  attention 
will  then  be  turned  to  other  matters. 
The  detection  of  the  foetal  form,  its  move- 
ments, ballottement,  the  sounds  of  the 
heart  and  the  placental  murmur  will  at 
once  settle  the  (juestion.  Still  later,  or  at 
the    full    term,    the  signs    of   a   spurious 


labour,  followed  by  diminution  of  size, 
will  influence  a  decision.  If,  after  this, 
the  process  of  encystraent  should  con- 
tinue, the  tumour  resulting  may  be  either 
fluctuating  or  solid.  With  an  accumula- 
tion of  fluid  in  the  amnion,  and  con- 
sequently no  diminution  of  size,  one 
must  resort  to  abdominal  ballottement, 
with  the  patient  on  hands  and  knees;  and 
in  that  position  the  remains  of  the  foetus 
would  generally  be  felt.  But  between  a 
solid  mass  of  a  date  longer  than  the  nine 
months  of  pregnancy  and  an  ovarian 
tumour,  judgment  will  be  mainly  influ- 
enced by  the  absence  of  the  symptoms  of 
pregnancy  during  the  early  stages  of 
development,  the  absence  of  false  labour 
at  or  near  the  end  of  the  natural  term, 
and  the  steady  regular  increase  in  size 
after  the  usual  period  of  gestation  has 
passed.  Finally,  it  is  self-evident  that  no 
ovarian  cyst  except  a  dermoid  can  come 
into  competition  with  one  of  these  con- 
ceptions which  has  had  the  privilege  of 
more  than  half  a  century  of  incubation, 
and  has  degenerated  into  a  substantial 
lardaceous  compound,  or  established  a 
claim  to  the  pompous  appellation  of 
lithopajdion. 

The  greatest  difficulty  in  diagnosis 
arises  when  the  uterus  either  undoubtedly 
contains  something,  or  is  enlarged  as 
in  pregnancy.  The  so-called  moles  or 
hydatids,  which  are  really  hydatidifbrm 
degeneration  of  the  chorion— intra-uterine 
polypus — cancer  of  the  body  and  fundus 
of  the  uterus,  while  the  cervix  remain.^ 
unaffected  —  ha;matometra,  hydrometra, 
and  physometra— are  all  conditions  which 
must  be  borne  in  mind,  and  which  may 
resemble  ovarian  tumours  in  some  par- 
ticulars, pregnancy  in  others. 

If  the  uterus  instead  of  a  foetus  sliould 
contain  a  mole,  the  breasts  may  swell,  the 
catamenia  cease,  and  all  the  other  signs  of 
pregnancy  may  be  present  for  a  time. 
Usually  molar  pregnancy  comes  to  an 
end  about  the  third  or  fourth  month,  but 
cases  are  on  record  Avhere  it  has  been 
protracted  to  the  thirteenth  and  fourteenth 
months;  and  Churchill  aUudes  to  a  case 
where  an  unmarried  woman  had  a  fre- 
quent discharge  of  'uterine  hydatids' 
throughout  her  menstrual  life.  In  molar 
pregnancy  the  uterus  does  not  enlarge 
so  regularly  as  in  ordinary  pregnancy. 
The  enlargement  is  usually  more  rapid, 
and  the  functional  disorders  are  more 
intense.     I  once  saw  a   Avoman    Avith    a 


DIFFERENTIAL  DIAGNOSIS   OF  OVARIAN  TUMOURS 


29 


supposed  ovarian  cyst,  fully  as  large  as  at 
the  end  of  a  normal  pregnancy.  While 
we  were  examining  her  in  the  out- 
patients' room,  uterine  contraction  came 
on ;  and  with  very  little  help  by  fingers 
in  the  vagina  and  pressure  on  the  abdo- 
men, nearly  a  pailful  of  these  'hydatids' 
was  expelled. 

An  intra-uterine  polypus  has  often 
been  mistaken  for  pregnancy.  After  the 
dilatation  of  the  cervical  canal,  and  com- 
mencing expulsion  from  the  os,  it  has 
«ven  been  supposed  that  abortion  or 
labour  was  going  on.  But  it  is  not  likely 
that  this  condition  would  be  nuKtaken  for 
ovarian  disease. 

Cancer  of  tlie  body  and  fundus  of  the 
uterus,  causing  enlargement  above  while 
the  cervix  is  unaffected,  may  be  taken  for 
an  ovarian  cyst  which  is  lying  above  the 
uterus,  or  for  pregnancy.  But  the  general 
cachexia,  uterine  discharge,  and  absence 
■of  fluctuation  Avill  be  sufficient  to  dis- 
tinguish this  condition  from  ovarian  dis- 
ease, and  some  of  the  characteristic  signs 
of  pregnancy  are  certain  to  be  absent. 

Collections  of  blood,  or  retained  clot, 
the  so-called  fibrinous  polypi,  or  of 
masses  of  dysmenorrhojal  membrane  with 
blood  or  clot,  all  conditions  described 
its  hajmatometra,  are  more  likely  to  be 
mistaken  for  pregnancy  than  for  ovarian 
disease  ;  but  some  of  the  signs  of  preg- 
nancy will  certainly  be  wanting,  and  the 
signs  of  enlarQ-ement  of  the  uterus  are 
sufficient  to  distinguish  this  condition 
from  ovarian  disease. 

Hydrometra,  again,  is  recognised  by 
the  enlargement  of  the  uterus  without  the 
other  characteristic  signs  of  pregnancy, 
before  any  watery  discharge  clears  up 
doubt.  Many  supposed  cases  of  hydro- 
metra have  imdoubtedly  been  cases  of 
ovarian  cysts  emptying  themselves  through 
the  Fallopian  tube  into  the  uterus  and 
vagina. 

Physometra  is  a  very  rare  condition — 
generally  the  result  of  decomposition  of 
part  of  a  retained  ovum,  or  of  blood  clot. 
The  resonance  on  percussion  of  the  en- 
larged uterus  is  sufficiently  characteristic. 
I  have  never  seen  a  case  where  a  collec- 
tion of  air  in  the  uterus  caused  an 
abdominal  tumour,  but  Dr.  Yarrow  of 
Washington  has  treated  the  subject  of 
Physometra  in  an  able  paper  published 
in  the  '  American  Journal  of  Obstetrics,' 
August  1883.  He  gives  the  history  of  a 
very  remarkable  case  where  an  abdominal 


tumour  extending  far  above  the  umbilicus, 
with  much  lateral  enlargement,  entirely 
disappeared  with  a  rush  of  pent-up  gas  de- 
void ot  odour,  on  passing  a  uterine  >-ound. 

Now,  bearing  in  mind  the  various 
symptoms  and  signs  of  pregnancy  while 
the  uterus  is  still  a  pelvic  tumour,  and 
afterwards  when  the  uterus  has  enlarged, 
risen,  and  become  an  abdominal  tumour, 
it  will  be  seen  how  they  resemble  and  how 
they  differ  from  those  which  characterise 
ovarian  cysts  and  tumours,  uterine  tumours, 
and  extra-uterine  foctation. 

When  an  ovary  is  only  slightly  tume- 
fied, it  usually  lies  behind  the  uterus  and 
may  be  felt  by  vagina  or  rectum,  or  better 
still  by  combined  examination  with  one 
finger  in  the  rectum  and  one  in  the  vagina. 
It  does  not  at  all  resemble  the  enlarging 
litems  of  early  pregnancy.  As  the  ovary 
swells,  it  usually  rises  up  out  of  the  pelvis  ; 
but  it  sometimes  remains  low  down  either 
from  pressure  or  adhesion,  and  as  it  grows 
it  pushes  the  uterus  either  to  one  side,  or 
backwards,  or  forwards.  It  may  restrict 
the  mobility  of  the  uterus,  but  the  inde- 
pendence of  the  one  of  the  other  may 
generally  be  made  out.  Increasing  in  size, 
the  ovary  may  rise  into  the  abdomen  and 
leave  the  uterus  quite  in  its  normal  posi- 
tion, without  any  deviation  or  modifica- 
tion of  mobility,  or  alteration  in  the 
cervix ;  or  it  may  drag  up  the  uterus 
quite  out  of  reach,  elongating  the  vagina, 
so  that  nothing  but  the  ovarian  tumour 
can  be  felt  through  the  vaginal  walls ; 
or  the  OS  may  just  be  reached,  high  up 
above  the  pubes  if  the  ovarian  cyst  is 
behind  the  uterus,  or  near  the  promon- 
tory of  the  sacrum  if  the  cyst  is  in  front. 
This  displacement  of  the  os  backwards 
by  a  cyst  in  front  of  it  simulates  preg- 
nancy, but  other  signs  are  wanting.  In 
case  of  doubt,  delay  of  a  month  or  two 
Avould  clear  it  up. 

It  is  possible  that  the  rate  of  growth 
of  an  ovarian  tumour  may  closely  resemble 
the  rate  of  the  enlargement  of  the  uterus 
in  pregnancy ;  but  it  is  much  more  likely 
to  advance  at  a  very  different  and  much 
less  regular  rate,  and  to  remain  for  Aveeks 
or  months  without  much  alteration  in  size. 
The  foetal  movements  and  heart  sounds 
are  wanting,  and  there  is  probably  a  less 
dense  or  solid,  if  not  a  distinctly  fluctuat- 
ing tumour. 

The  distinction  between  pregnancy  and 
fibroid  tumour  or  enlargement  of  the 
uterus  will  be  alluded  to  hereafter. 


30 


OVARIAN  AND  ALLIED  TUMOURS 


RENAL    CYSTS    AND    TUJIOUKS 

The  diagnosis  of  ovarian  tumours  from 
cystic  growths  and  enlargements  of  the 
kidneys  is  usually  made  with  a  readiness 
which  renders  a  mistake  quite  an  excep- 
tion. But  occasionally  an  exact  diagnosis 
is  impossible.  And  sometimes,  it  is  only 
after  an  exploratory  operation,  or  after 
the  death  of  the  patient,  that  a  mistake  is 
discovered. 

The  first  case  of  the  kind,  which  came 
imder  my  care,  was  one  of  soft  cancer  of 
the  right  kidney  in  a  girl  only  four  years 
old.  She  was  supposed  to  be  suffering 
from  ovarian  disease.  Her  appearance  is 
shown  in  the  woodcut. 


The  diagnosis  in  this  case  Avas  made 
without  much  difficulty,  although  the 
urine  was  quite  normal.  The  groAvth  was 
extremely  rapid  ;  hardly  six  months  from 
its  commencement  to  its  fatal  termination 
— wlicn  the  diseased  mass  weighed  be- 
tween 16  and  17  pounds.  The  tumour 
occupied  the  whole  of  the  right  side  of 
the  abdomen,  bulging  backwards  in  the 
right  loin.  It  was  uniformly  ehistic, 
but  no  fluctuation  could  be  detected.  The 
intestines  were  pushed  downwards,  and  to 
the  left  side.  The  rapid  growth,  and  the 
absence  of  fluctuation,  were,  of  course, 
strongly  against  the  opinion  that  the  tu- 
mour was  ovarian ;  while  the  rarity  of 
ovarian  disease  in  young  children,  and  the 


comparative  frequency  of  renal  encephaloid, 
led  to  a  diagnosis  which  was  confirmed  by  a 
puncture  with  a  fine  exploring  needle.  A 
few  drops  of  reddish  serum  were  obtained, 
containing  nucleated  cells  of  varied  size 
and  shape.  After  death  the  whole  kidney 
was  found  infiltrated  with  encephaloid. 
Although  so  enormously  enlarged,  the 
shape  of  a  normal  kidney  was  distinctly 
preserved.  Its  surface  was  soft  and  elastic, 
in  some  spots  giving  a  sense  of  deep-seated 
fluctuation ;  but  no  cyst  was  found,  nor 
were  there  any  marks  of  suppuration  or 
hcemorrhage.  Coils  of  small  intestine 
adhered  to  its  inner  and  under  surface. 
The  ureter  was  occluded  by  the  pressure 
of  the  tumour.  The  left  kidney  was 
quite  healthy.  Thus  the  normal  condi- 
tion of  the  urine  was  explained.  The 
diseased  kidney  added  nothing  to  the  con- 
tents of  the  bladder,  and  the  healthy 
kidney  supplied  only  normal  urine. 

The  following  remarks  on  this  point 
by  Dr.  Roberts,  of  Manchester  ('  Urinary 
and  Renal  Diseases,'  p.  444),  are  well 
worthy  of  serious  consideration.  He  says  : 
'  The  presence  of  cancer  cells  in  the  urine 
is  a  sign  which  usually  figures  prominently 
in  the  catalogue  of  symptoms  of  renal 
cancer,  but  its  value  is  very  doubtful.  It 
is  by  no  means  an  easy  matter  to  identify 
cancer  cells  in  the  urine,  in  consequence 
of  their  similarity  to  the  transitional 
epithelium  of  the  pelvis  and  ureter.  .  .  , 
In  two  examples  of  renal  cancer,  with 
hematuria,  which  I  have  had  an  opportu- 
nity of  observing,  repeated  and  careful 
examination  of  the  urine  failed  to  dis- 
cover the  presence  of  cancer  cells.  IMr. 
Moore  ('Med.  Chir.  Trans.'  xxxv.  46G) 
believes  that  he  sixcceeded  in  identifying 
cancer  cells  in  the  urine  drawn  after  death 
from  the  bladder  of  a  man  in  whose 
kidneys  cancerous  nodules  were  found  ; 
but  his  description  rather  accords  with 
the  appearance  of  the  epithelial  cells  which 
are  always  freely  detached  from  the  vesical 
mucous  membrane  after  death.' 

Whether  renal  cancer  be  observed  in 
children  or  in  adults — whether  it  be  or  be 
not  accompanied  by  hccmaturia,  or  by  the 
presence  in  the  urine  of  albumen,  or  of 
epithelial  cells  from  the  ureter  and  pelvis 
of  the  kidney — Avhcther  the  progress  of 
the  disease  be  slow  or  rapid — whether 
there  may  be  much,  little,  or  no  pain,  or 
emaciation,  or  gastric  symptoms — or  great 
or  little  effect  upon  the  general  health — 
the  abdominal  tumour  is  the  most  pro- 


DIFFEKENTIAL  DIAGNOSIS   OF  OVARIAN   TUMOURS 


31 


minent  characteristic  of  the  disease.  As 
Brieht  observed  ('  Abdominal  Tumour?,' 
Syd^enham  Society's  Edit.  p.  199)  :  '  The 
enlargement  shows  itself  much  more 
towards  the  anterior  part  of  the  abdomen 
than  towards  the  loins.'  It  is,  however, 
more  or  less  confined  to  one  side  of  the 
abdomen  and  to  the  corresponding  lumbar 
region,  whence,  as  a  rule,  it  is  immovable 
— and,  equally  as  a  rule,  some  portion  of 
the  intestines  are  fixed  in  front  of  it.  But 
in  one  case  an  exception  was  found  to 
these  rules.  In  the  '  Lancet '  of  March 
1865  a  case  is  recorded  in  which  an 
operation  was  commenced  for  the  removal 
of  a  supposed  tumour  of  the  left  ovary. 
The  patient  was  in  one  of  our  general 
hospitals,  and  it  was  believed  that  '  the 
tumour  was  ovarian,  and  that  from  its 
great  mobility,  and  the  absence  of  adhe- 
sions, its  removal  would  be  easy.'  Yet 
the  uterus  and  ovary  were  found  to  be 
healthy,  and  the  tumour  to  be  the  en- 
larged left  kidney ;  wliich,  instead  of 
being  fixed,  was  movable — its  peritoneal 
covering  being  elongated  into  a  sort  of 
mesentery,  admitting  of  free  movements 
— and,  instead  of  pushing  the  intestines 
before  it,  the  descending  colon  and 
sigmoid  flexure  were  behind  it.  This 
enlargement  of  a  movable  kidney  added 
greatly  to  the  difficulty  of  diagnosis. 

The  absence  of  fluctuation  is  the  lead- 
ing sign  by  which  cancerous  or  other  solid 
tumours  of  the  kidneys  are  distinguished 
from  ovarian  tumours ;  for  it  is  extremely 
rare  to  find  a  large  ovarian  tumour  in 
some  part  of  which  fluctuation  cannot 
be  detected.  But  in  some  forms  of 
kidney  disease  fluctuation  is  as  evident  as 
in  ovarian  cysts.  In  one  case  of  pyo- 
nephrosis I  punctured  the  kidney  through 
the  abdominal  Avail,  and  so  not  only 
cleared  up  the  diagnosis,  but  restored  the 
patient  to  many  years  of  health.  Cystic 
degeneration  was  in  another  woman 
attended  with  symptoms  so  exactly  the 
same  as  those  seen  in  enlargements  from 
ovarian  tumours,  that  I  only  learnt  the 
true  nature  of  the  disease  by  an  abdominal 
incision.  And  in  one  of  my  patients  the 
enormous  bulk  of  a  fibro-plastic  tumour 
originating  in  the  right  kidney  or  its 
peritoneal  covering,  and  weighing  84 
pounds,  effectually  obscured  ail  indica- 
tions to  be  gathered  from  manipulation 
either  externally  or  by  the  vagina. 

It  is  evident  from  the  cases  just  men- 
tioned that  both  solid  and   cystic  tumours 


of  the  kidney  may  be  mistaken  for  ovarian 
tumours.  Solid  renal  tumours,  whether 
cancerous  or  innocent,  may  resemble  the 
malignant,  pseudo-colloid,  or  cysto-sarco- 
matous  tumours  of  the  ovaries ;  while  dif- 
ferent varieties  of  ovarian  cysts  may  be 
closelv  simulated  by  different  forms  of 
pyelitis  and  pyonephrosis,  hydronephrosis, 
cystic  degeneration,  and  the  growth  of 
hydatids  in  the  kidney.  The  diagnosis 
may  be  facilitated  by  attention  to  the 
following  propositions  : 

1.  Although  intestine  is  sometimes 
found  in  front  of  ovarian  tumours,  and 
sometimes  behind  movable  renal  tumours, 
these  are  very  rare  exceptions  to  the 
general  rule  that  renal  tumours  press  the 
intestines  forward,  and  ovarian  tumours 
press  tliem  backward.  In  other  words, 
ovarian  tumours  are  in  front  of  the  intes- 
tines, renal  tumours  are  behind  the  intes- 
tines. 

2.  Large  tumours  of  the  right  kidney 
usually  have  the  ascending  colon  on  the 
inner  border  of  the  tumour.  Tumours  of 
the  left  kidney  are  usually  crossed  from 
above  downwards  by  the  descending 
colon. 

3.  The  discovery  of  intestine  in  front 
of  a  doubtful  abdominal  tumour  should 
lead  to  a  careful  examination  of  the  urine. 
It  is  possible  that  one  kidney  may  be 
diseased  and  the  urine  quite  normal, 
because  the  healthy  kidney  alone  secretes 
urine.  But  the  rule  is  that  either  blood, 
pus,  or  albumen,  or  characteristic  epithe- 
lium, is  detected — or  some  history  may 
be  elicited  of  their  having  been  detected 
at  some  former  period. 

4.  If  any  doubt  be  entertained  whether 
a  substance  felt  between  an  abdominal 
tumour  and  the  integument  be  or  be  not 
intestine,  percussion  will  not  always  solve 
the  doubt,  because  the  intestine  may  be 
empty  and  compressed.  But  (a)  an 
intestine  when  rolled  imder  the  fingers 
contracts  into  a  firm,  cord-like,  movable 
I'oll ;  (b)  the  patient  may  be  conscious  of 
the  giirgling  of  flatus  along  it,  or  the 
gurgling  may  be  heard  on  auscultation  ; 
(c)  the  intestine  may  be  distended  by 
insufflation,  after  passing  a  long  elastic 
tube  through  the  rectum. 

5.  Ovarian  and  renal  cysts  may  both 
be  subject  to  i;reat   alterations   in   size. 

j  When  the   kidney  is  the  seat  of  disease 

'  the  fluid  usually   escapes  by  the  ureter 

I  and  bladder.     An  ovarian  cyst  can  only 

empty  itself  through  the  bladder,  or  into 


?.9. 


OVAPJAX   AND   ALLIED   TUMOURS 


an  intestine,  or  through  the  coats  of 
the  vagina,  after  adhesion  and  a  fistulous 
opening.  It  may  discharge  through  the 
Fallopian  tube  and  uterus.  In  either 
case  the  physical  and  chemical  characters 
of  the  Huid  discharged  will  be  the  chief 
guide  in  diagnosis. 

6.  If  a  correct  history  can  be  ob- 
tained, it  may  be  expected  that  a  renal 
tumour  has  first  been  detected  between 
the  fiilse  ribs  and  ilium,  and  that  it  has 
extended  first  towards  the  umbilicus,  next 
into  the  hypochondrium,  and  lastly  down- 
wards towards  the  groin.  An  ovarian 
tumour  has,  in  all  probability,  been  first 
noticed  in  one  inguinal  or  iliac  region, 
lind  has  extended  upwards  and  inwards, 

7.  It  is  only  a  very  small  ovarian 
tumour,  with  a  long  pedicle,  which  could 
be  mistaken  for  a  floating  or  movable 
kidney.  The  latter  may  be  recognised 
by  its  chai-acteristic  shape,  though  it  is 
olten  so  misplaced  that  the  hilus  is 
turned  upwards.  The  kidney  is  usually 
felt  between  the  umbilicus  and  the  false 
ribs,  and  may  be  pushed  upwards  and 
downwards,  or  laterally,  to  a  varying 
extent,  or  into  the  lumbar  region  to  the 
normal  position  of  the  kidney.  When 
the  kidney  is  pushed  away  from  this 
position,  the  sound  on  percussion  there 
becomes  tympanitic. 

8.  Just  as  renal  tumours  are  usually 
associated  with  some  evidence  or  history 
of  hasmaturia,  calculus,  albuminuria,  ne- 
phritic colic,  or  some  notable  change  in 
the  quantity  or  state  of  the  urine,  so 
ovarian  tumours  are  usually  associated 
with  some  change  in  the  quantity  and 
regularity  of  the  discharge,  or  with  suffer- 
ing at  the  catamenial  periods,  and  wdth 
some  alteration  in  the  mobility  or  situa- 
tion of  the  uterus.  But  as  in  some  rare 
•cases  of  renal  disease  the  urine  may  be 
normal,  so  in  some  rare  cases  of  ovarian 
disease  there  may  be  nothing  abnormal 
to  be  discovered  in  any  of  the  pelvic 
viscera,  nor  in  their  functions. 

By  bearing  these  facts  in  mind  an 
accurate  diagnosis  may  Ije  made  in  a 
very  large  proportion  of  cases.  Some 
rare  cases  of  exceptional  difficulty  may, 
Iiowever,  be  occasionally  expected. 

DISTENDED  BL.\DDi:i: 

A  word  of  caution  may  not  be  super- 
fluous, reminding  the  young  practitioner 
that  the  bladder,   distended  with  urine, 


has,  in  several  instances,  formed  a  tumour, 
which  has  been  mistaken  either  for  aii 
ovarian  cyst  or  for  ascites,  and  has  been 
tapped,  in  some  cases  with  a  fatal  result. 
I  was  once  present  in  an  hospital  when  a 
woman  was  about  to  be  tapped.  The 
peculiar  projection  immediately  above 
the  pubes  at  once  struck  me,  and  I 
suggested  that  the  catheter  should  be  in- 
troduced. Five  pints  of  urine  passed,  and 
thetamour  disappeared.  In  this  case  the 
patient  was  supposed  to  be  suffering  from 
incontinence  of  urine  from  pressure  of 
the  imaginary  cyst.  But  the  urine  which 
dribbled  away  was  simply  overflow 
from  the  jiaralysed  bladder.  Distension 
of  the  bladder  is  of  common  occurrence 
both  in  uterine  and  ovarian  tumours 
which  are  fixed  in  the  pelvis.  In  some 
cases  it  is  only  by  the  use  of  a  small  and 
long  elastic  catheter  that  the  bladder  can 
be  reached  and  emptied.  This  is  espe- 
cially necessary  in  cases  of  uterine  tu- 
mour, where  it  is  not  rare  to  find  the 
bladder  drawn  up  nearly  to  the  level  of 
the  umbilicus.  In  some  cases  of  cancer 
of  the  bladder,  where  the  growth  extends 
to  the  uterus,  and  the  bladder  is  distended 
with  urine,  mistakes  are  only  avoided  by 
using  the  catheter. 

F.ECAL    ACCUMULATIONS 

In  his  *  Clinical  Lectures  on  the 
Diseases  of  Women,'  Simpson  says  that 
there  had  been  'in  the  hospital  a  patient 
who  was  sent  from  the  country,  and 
presented  on  admission  the  colour  and 
appearance  of  a  person  labouring  under 
some  malignant  disease.  The  facial  ex- 
pression might  have  led  you  to  believe 
that  she  was  the  subject  of  a  cancerous 
diathesis.  She  had  a  tumour  in  the  left 
hypogastric  region,  about  the  size  of  a 
fist.  But  under  the  use  of  croton  oil  it 
readily  disappeared,  and  proved  to  be 
only  a  mass  of  fa3ces  in  the  colon.  You 
might  suppose  that  it  would  be  difficult 
to  mistake  such  a  tumour  for  any  kind  of 
morbid  growth,  and  you  might  imagine 
that  the  patient  would  be  suffering  from 
sucli  a  degree  of  constipation  as  at  once 
to  indicate  its  real  nature.  But  there  is 
not  of  necessity  any  degree  of  constipa- 
tion ])resent.  On  the  contrary,  there  is 
sometimes  diarrhoea.  The  peculiar  feel- 
ing of  such  a  tumour  will  generally 
enable  you  to  decide  as  to  its  true 
character  :  it  feels  like  no  tumour  that  I 


DIFFERENTIAL  DIAGNOSIS   OF  OVAIIIAN   TUMOURS 


know  of.  On  being  examined  either 
through  the  abdominal  walls  or  through 
the  rectum,  it  is  felt  to  be  hard  and  re- 
sistant; but  if  one  finger  be  pressed 
steadily  iipon  it  for  one  or  two  minutes, 
it  Avill  at  last  indent  like  a  hard  snowball, 
and,  as  there  is  not  the  slightest  elasticity 
about  it,  the  indentation  remains  after 
the  pressure  is  removed.  If  any  doubt 
should  still  remain,  the  persevering  use  of 
aperients  will  clear  up  for  you  the  dia- 
gnosis by  causing  the  mass  to  be  dissolved 
zxnd  carried  off.' 

Although  I  have  several  times  seen 
iLimps,  which  were  fajcal  accumulations, 
in  the  region  of  the  cfccum  and  ascending 
colon,  yielding  to  the  pressure  of  the 
finger,  and,  owing  to  their  containing 
or  being  surrounded  with  gas,  having  a 
degree  of  resonance  on  percussion,  yet  I 
have  only  met  with  one  of  such  a  size  as 
to  be  mistaken  for  an  ovarian  tumour. 

Some  years  ago  I  was  summoned  to 
■Chester,  and  on  arriving  found  that  the 
case  was  one  of  obstructed  intestine. 
Stercoraceous  vomiting  had  been  going 
on  for  many  days,  and  the  lady  was 
almost  moribund.  The  abdomen  was 
distended  beyond  the  ordinary  size  at  the 
full  time  of  pregnancy,  by  a  well-defined 
solid  ttmiour,  which  I  should  have 
imagined  to  be  uterine  or  ovarian  but 
that  it  was  semi-resonant  on  percussion. 

Consulting  with  Dr.  Waters  as  to  the 
performance  of  Amussat's  or  Nekton's 
■operation,  I  thought  it  better  to  com- 
mence by  an  exploratory  incision,  in 
order  to  ascertain  what  the  abdominal 
tumour  was.  On  dividing  the  peritoneum 
the  tumour  appeared  exactly  like  a  very 
'large  uterus,  but  on  passing  my  hand 
under  its  lower  border  I  found  the  uterus 
and  both  ovaries  healthy.  On  percussing 
the  tumour  there  was  sufficient  resonance 
to  show  that  it  was  either  intestinal  or  a 
•cyst  containing  air,  and.  further  examina- 
tion convinced  me  that  it  was  the  cajcum 
■and  colon  enormously  distended.  I 
accordingly  performed  a  modified  Nek- 
ton's operation,  first  stitching  the  peri- 
toneal coat  of  the  cascum  to  the  peritoneal 
edges  of  the  incision  in  the  abdominal 
wall  and  then  opening  the  gut.  More 
than  two  pailfuls  of  semi-solid  ftecal 
matter  escaped,  and  the  gut  rapidly 
contracted  as  it  became  empty.  I  could 
not  ascertain  what  the  cause  of  the 
obstruction  had  been.  The  patient  re- 
covered, and  some  months  afterwards  I 


closed  the  artificial  anus.  She  died  ia 
1884.  No  examination  of  the  body  was 
made. 


PELVIC    CLLLULITIS    AND    ABSCESS 

It  is  not  often  that  ovarian  tumours, 
even  when  they  are  confined  below  the 
brim  of  the  pelvis,  are  mistaken  for  pel- 
vic cellulitis  or  abscess.     But  it  is  pro- 
bable that  many  of  the  cases  of  supposed 
cures  of  ovarian  or  uterine  tumours  were 
merely  inflammatory  exudations  into  the 
pelvic  cellular  tissue,  which  were  either 
removed  by  absorption  or  terminated  in 
suppuration    and   the    discharge    of    the 
pus   by  the  rectum,    vagina,  bladder,  or 
skin.     In    1871   I   saw  a   lady  Avho   had 
been    supposed    to    suffer  from    ovarian 
disease,    in  whom  a  pelvic  abscess   dis- 
charged not  only  through  the  rectum,  the 
bladder,  the  vagina,  and  in  one  loin,  but 
gravitating  down  the  leg,  opened  in  the 
calf.     A    suppurating  ovarian  cyst  may 
end  in  the  same  way  ;  but  the  history  of 
the  case,  the  severe  pain,  the  high  tem- 
perature at  the  onset  of  the  disease  before 
any  considerable  tumour  had  formed,  the 
remarkable  almost  bonelike  hardness  and 
fixity  of  the   swelling,   as  if  inseparably 
connected  with  one  or  other  ilium,  and 
the  flexure  of  the  thigh  from  the  way  in 
which  the  psoas  muscle  is  involved,  are 
sufficiently  characteristic  of  cellulitis.     It 
is  very  seldom  that  an  ovarian  cyst  shows 
any  tendency   to    point   in   the  situation 
where  there  is  the  greatest  tendency  to 
point  in  pelvic  abscess,  that  is  in  the  roof 
of  the  vagina,  very  near  the  cervix  uteri, 
either  behind  or  in  front  or  to  one  side  of 
it.     An  ovarian  cyst,  or  a  pelvic  abscess 
which  had  burst  into  the  peritoneal  cavity, 
would  be  attended  by  the  same  symptoms 
of  perforating   peritonitis.     Bat   in    one 
case  the  previous  history  would  have  been 
that  of  pelvic  cellulitis,  in  the  other  that 
of  an    ovarian   cyst    which    had    beco:ne 
inflamed,   or   had  burst  after   twisting  of 
the  pedicle.     It  is  seldom   that  a  pelvic 
abscess  extends  upwards  above  the  imi- 
bilical  level.     Hardness  may  be  felt  in 
one  or   other  iliac   region    or  above   the 
pubes,  and  a  corresponding  hardness  or 
swelling  may  be  felt  by  the  vagina,  behind 
or  in  front  or  to  one  side  of  the  uterus ; 
and,  if  pus  have  formed,  fluctuation  may 
be  detected.     An  ovarian  cyst  is  not  so 
firmly  fixed  in  the  pelvis  ;  even  if  adherent 
there,  it  does  not  give  the  same  impression 


34 


OVARIAN   AND   ALLIED   TUMOURS 


of  close  attachment  to  the  pelvic  bones. 
It  rarely  leads  to  such  troublesome 
dysuria,  to  such  rectal  pain  or  tenesmus, 
to  such  constant  throbbing,  or  to  such 
enforced  quiescence  of  one  or  both  lower 
limbs;  and  the  general  outline  of  an  ova- 
rian cyst  can  be  more  easily  traced  than 
the  diffuse  bulging  of  a  pelvic  abscess. 
The  swelling  in  pelvic  abscess  is  harder, 
more  painful  on  pressure,  and  accom- 
panied with  nervous  pains  such  as  are 
usually  called  sciatica  or  pelvic  neuralgia. 
It  is  not  often  that  an  ovarian  cyst  sup- 
purates until  it  has  existed  for  many 
months,  or  has  attained  a  large  size;  but 
the  whole  course  of  a  pelvic  abscess,  from 
its  commencement  till  the  discharge  of 
■piis  is  effected,  is  seldom  more  than  from 
3  to  4  weeks. 

ILEJrATOCELE 

As  in  pelvic  cellulitis,  so  in  ha^mato- 
cele,  it  is  only  a  small  ovarian  tumour 
■which  has  not  risen  out  of  the  jDclvis,  or 
a  large  ovarian  cyst  Avhich  has  suppurated, 
that  could  be  mistaken  for  either  the 
early  and  small  or  the  later  and  large 
stages  of  pelvic  cellulitis  or  hsematocele. 
A  small  hematocele  in  the  early  stage 
produces  much  the  same  local  conditions, 
is  accompanied  by  very  similar  pain,  and 
almost  as  much  general  fever  as  pelvic 
cellulitis,  and  is  apt  to  be  associated  with 
about  the  same  amount  of  pelvic  peri- 
tonitis. Indeed,  it  is  very  probable  that 
many  of  the  cases  of  pelvic  cellulitis  take 
their  origin  from  a  ha^matocele.  Some 
blood  escapes  into  the  loose  cellular  tissue 
in  the  neiglibourhood  of  the  litems  about 
the  time  of  menstruation  ;  a  clot  forms, 
does  little  harm  by  itself,  but  pelvic 
cellulitis  is  set  up,  which  ends  in  abscess, 
the  clot  which  excited  it  disappearing. 
It  is  only  when  the  effusion  of  blood  is 
large  and  sudden,  its  escape  through  the 
Fallopian  tube  prevented,  and  its  general 
diffusion  in  the  peritoneal  cavity  limited 
>)y  peritonitis  and  adhesions,  that  a  dis- 
tinct pelvic  or  abdominal  tumour  is 
formed.  It  is  rarely  that  such  a  tumour 
extends  as  high  up  as  the  umbilical  level; 
more  frefjuently  it  is  either  within  the 
pelvis,  behind  or  to  one  or  other  side  of 
tlie  uterus,  and  barely  to  be  felt  through 
the  abdominal  wall.  Tliese  characters  are 
quite  sufhcient  to  distinguish  it  from  a 
large  ovarian  cyst.  Small  ovarian  cysts 
do  not  commence  so  suddenly,   are  not 


so  closely  associated  with  the  catamenial 
period,  nor  is  their  advent  ushered  in  by 
such    acute  pain   or  febrile    disturbance. 
An  ovarian  cyst  is  seldom  dangerous  to 
the    life    of    the    patient    before    it    has 
attained     considerable    size,    Avhereas    a 
ha?matocele  of  very  moderate  extent  and 
of  sudden  formation  may  be  either  rapidly 
fatal  or  lead  to  very  dangerous  symptoms. 
The  following  narrative  may  serve  to 
illustrate  the  above  remarks,  and  I  have 
seen  several  similar  cases.     A  young  lady 
was  travelling  from  Paris  to  London.  She 
was  menstruating  and  caught  cold.     The 
day  after  her  arrival  there  was  consider- 
able swelling  in  the    right    iliac   region, 
with  extreme  tenderness.    The  symptoms 
became  more  intense  during  the  next  few 
days,   and  when   1  saw  the   patient  her 
sufferings   were    so    excessive    that    the 
examination  could  only  be  made  when 
che  was  under  the  infiaence  of  chloroform. 
The  abdominal  swelling  was  principally 
confined  to  the  right  side,  and  extended 
as  high  as  the  fidse  ribs.    The  uterus  was 
fixed,  pushed  forwards  and  to   the  left, 
and  there   was  distinct  pointing  in  the 
vagina  behind    and   to    the  right  of  the 
uterus.     The  possibility  of  the  existence- 
of  an  ovarian    cyst   which    had   rapidly 
enlarged   and   become    acutely   inflamed 
was  carefully  considered,  but  the  history 
of  the  case  indicated  so  clearly  ha^matocelev 
followed    by    pelvic   abscess,   wdiich   was 
pointing  towards  the  vagina,  that  puncture 
by  the  vagina  was  urged,  and  was  only 
deferred  oAving  to  the  absence  of  a  member 
of  the  family,  and  in  the  hope  that  as  the 
abscess  was  distinctly  pointing  it  would 
open  spontaneously.     A  few  hours  after 
this  consultation,  sudden  collapse  and  the 
well-known     symptoms     of     perforating 
peritonitis  set  in,  followed  by  death  the 
next  day.     In  another  case,  a  ha^matocele 
passed  below  Poupart's  ligament,  and  I 
opened   it   in   the  thigh.     It   was   com- 
pletely cured  by  drainage.     It  had  been 
taken  for  psoas  abscess  and  spinal  disease; 
but  examination  l)y  the  vagina  led  to  a 
correct  diagnosis. 

As  curiosities  of  surgical  experience, 
but  not  arising  sufficiently  often  to  call 
I'or  more  than  passing  notice,  and  as 
morbid  changes  Avhich  may  possibly  be 
mistaken  for  ovarian  disease,  may  be 
enumerated  encephaloid  tumour  of  the 
ilium,  enchondroma  or  osseous  tumours, 
projecting  from  the  sacrum,  angular 
curvature     of     the     lumbar     vertebra;. 


DIFFERENTIAL   DIAGNOSIS   OF   OVARIAN  TUMOURS 


oO 


enlargement  or  malignant  disease  of  the 
lumbar  glands,  or  dissecting  aneurism 
of  the  aorta.  I  know  of  one  case  where 
a  tumour  in  the  pelvis  was  punctured  by 
tlie  vagina  ;  the  patient  died  from  bleed- 
ing beibre  the  surgeon  leil  the  room,  and 
after  death  it  Avas  found  that  an  aneurism 
of  the  aorta  above  the  bifurcation  had 
dissected  downwards  behind  the  peri- 
toneum, and  formed  a  considerable  tu- 
mour in  the  hollow  of  the  sacrum.  I 
have  seen  three  cases  where  encephaloid 
disease,  arising  in  the  cancellated  bouy 
tissue  of  the  ilium,  had  not  only  pro- 
jected backwards  and  towards  the  but- 
tock, but  so  far  inwards  and  upwards  as 
to  form  a  considerable  abdominal  tumour. 
In  one  of  these  cases  the  abdominal  tu- 
mour transmitted  a  distinct  pulsation 
from   the  aorta.     In  another  the  growth 


itself  was  pulsatile.  In  the  third  the 
rectum  was  completely  occluded  by  the 
growth.  The  other  states  above  enume- 
rated scarcely  need  further  remark ;  a 
little  attentive  consideration  of  the  history 
and  progress  of  the  cases  will  be  sufficient 
to  distinguish  them  from  any  form  of 
ovarian  disease. 

The  accompanying  woodcut  may  serve 
to  illustrate  a  combination  of  retroverted 
gravid  uterus  Avith  distended  bladder, 
which  might  possibly  become  the  cause 
of  an  error  in  diagnosis. 

As  a  sequel  to  the  preceding  observa- 
tions on  diagnosis,  it  is  well  to  draw 
attention  to  the  best 

MODE    OF    INVESTIGATING    AND    HECOHDING 
CASES 

Whenever  a  patient  with  an  ab- 
dominal tumour   falls   under   the   notice 


of  a  medical  student,  or  consults  a 
practitioner,  the  case  should  be  investi- 
gated and  recorded.  It  requires  a  great 
deal  of  practice  to  do  this  in  a  systematic 
manner.  Much  that  has  Ijeen  said  on 
the  diagnosis  of  ovarian  from  other  ab- 
dominal tumours,  and  of  the  different 
kinds  of  ovarian  tumours,  should  be 
borne  in  mind ;  but  something  is  very 
likely  to  be  overlooked  if  the  investi- 
gation is  not  conducted  methodically.  I 
very  soon  found  that  the  best  and  most 
convenient  plan  was  to  have  a  separate 
note-book  for  every  patient,  and  successive 
editions  of  this  note-book  have  been  pub- 
lished by  Messrs.  Churchill — the  sixth  in 
1881.  Translations  have  appeared  both 
in  French  and  Italian.  I  and  many  of 
my  friends  have  found  these  note-books 
so  useful,  that  I  can  with  considerable 
confidence  recommend  their  general  use. 

On  the  first  introduction  of  a  patient, 
one  of  these  note-books  is  inscribed  with 
her  name  and  number  of  reference,  and 
any  letter  received  from  the  usual  medical 
attendant,  or  from  any  friend  of  the 
patient,  may  be  pasted  in.  Years  after- 
wards the  advantages  of  this  habit  of 
preserving  the  originals,  rather  than 
copying  extracts,  may  be  found.  As 
the  note-books  accumulate,  they  may 
be  arranged  in  distinct  divisions,  accord- 
ing to  the  nature  of  the  case,  and  bound 
together  about  twenty  to  each  volume. 

As  soon  as  a  patient  is  seen,  a  note- 
book is  taken,  and  the  first  page  is  at 
once  filled  up.  The  date  of  the  visit  is 
inserted  with  the  index  number,  and  then 
a  few  questions  are  necessary  to  enable 
one  to  fill  in  the  answers  as  to  name,  age, 
residence,  occupation,  conjugal  condition, 
number  and  ages  of  any  children,  and 
the  name  of  the  usual  medical  attendant. 
It  saves  a  great  deal  of  trouble  in  after 
years  if  these  particulars  are  noted  very 
fully  and  accurately ;  and  the  surgeon 
may  then  proceed  to  note  all  that  he  can 
see  and  ascertain  for  himself  by  inspection 
of  the  patient,  before  he  proceeds  to  ques- 
tion her  further.  This  plan  will  be  found 
to  save  much  time,  the  subjective  exami- 
nation being  limited  to  particulars  Avhich 
the  objective  examination  has  shown  to 
be  important.  Even  then  the  first  visit 
or  consultation  is  necessarily  a  long  one  ; 
but  time  and  thought  and  tax  on  memory 
are  spared  at  subsequent  visits. 

It  will  be  observed  that  four  pages  are 
taken  up  by  the   objective  examination, 

D  2 


\i} 


OVARIAN  AND  ALLIED  TUMOURS 


or  the  notes  of  what  the  surgeon  can  ' 
see  for  himself  without  asking  any  ques- 
tions of  the  patient.  These  are  grouped 
under  the  general  head,  '  State  at  First 
Visit.'  All  the  particulars  as  to  the  general 
appearance  of  the  patient,  her  complexion, 
the  degree  of  emaciation,  her  habits  of 
life,  and  the  state  of  the  surface  of  her 
body,  have  some  special  signification, 
as  pointed  out  in  the  preceding  pages  on 
Diagnosis. 

Proceeding  to  inspect  and  measure 
the  abdomen,  a  diagram  (which  differs  from 
those  of  Bright  and  others  in  so  far  as  it 
has  been  corrected  by  photographs  of  well- 
formed  women)  on  page  3  of  the  Note- 
Book  will  assist  the  observer  in  trac- 
ing such  outlines  of  the  liver  and  the 
spleen  and  thoracic  viscera  as  he  can  dis- 
cover by  inspection,  palpation,  and  per- 
cussion, and  of  any  tumour  which  can  be 
seen  or  felt.  A  column  is  marked  for  the 
measurements,  in  inches,  of  the  girth  at 
the  umbilical  level — of  the  distance  from 
ensiform  cartilage  to  umbilicus,  from 
umbilicus  to  symphysis  pubis,  and  from 
umbilicus  to  right  and  left  anterior 
superior  iliac  spine.  Spaces  are  leifc  for 
subsequent  records  of  size.  At  pages 
5,  6,  the  import  of  the  visible  mobility 
of  any  tumour,  and  the  evidence  as  to  the 
presence  and  extent  of  adhesions,  have 
been  pointed  out ;  and  the  lessons  to  be 
learned  by  percussion  and  auscultation 
have  been  particularly  referred  to  in  the 
sections  on  Ascites,  Renal  Cysts,  Preg- 
nancy, Uterine  Tumours,  and  Tym- 
panites. The  points  to  be  observed  in 
the  examination  of  the  pelvis  have  been 
fully  described  when  considering  the 
diagnosis  of  pelvic  cellulitis,  hematocele, 
uterine  tumours,  and  pregnancy.  It  is 
hardly  necessary  to  add  the  very  obvious 
caution  not  to  use  the  sound,  to  ascertain 
the  length  of  the  uterine  cavity,  in  any 
case  where  pregnancy  is  at  all  probable. 
But  it  may  not  be  out  of  place  to  urge 
that  examination  of  the  uterus  by  the 
rectum  is  often  more  useful,  and  affords 
much  more  information,  than  is  commonly 
supposed.  By  the  vagina  the  os  and 
cervix  are  felt  and  any  flexion  or  version 
detected ;  but  alterations  in  the  body  or 
fundus,  which  cannot  be  reached  by  the 
vagina,  may  often  be  felt  through  the 
rectum. 

Proceeding  to  obtain  information  as 
to  the  catamenia,  a  few  questions  become 
necessary;   and   so   with   regard   to   the 


urinary  and  digestive  organs,  the  nervous 
system,  and  the  state  of  the  heart  and 
lungs.  In  an  hospital  the  house  surgeon 
or  clinical  clerks,  and  in  private  life  the 
busy  practitioner,  are  apt  to  pass  over 
these  pages  as  of  no  great  importance,  or 
to  defer  the  necessary  examination  to 
some  future  day ;  but  it  is  very  impor- 
tant that  it  should  be  done  well  and 
thoroughly  before  any  course  of  treatment 
is  determined.  These  points  are  all  indi- 
cated, and  room  left  for  answers  to  ques- 
tions on  pages  4,  5,  6,  and  7  of  the  Note 
Book. 

Having  completed  the  examination  as 
to  the  state  of  the  patient  at  the  first  visit, 
the  page  (8)  relating  to  the  family  history, 
place  of  birth  and  residence,  the  influence 
of  soil,  climate,  water-  supply  and  drain- 
age, and  the  mode  of  life  of  the  patient 
should  be  filled  up,  especially  noting  any 
moral  causes,  previous  diseases,  or  acci- 
dents which  may  have  preceded  and 
possibly  have  influenced  the  origin  and 
progress  of  ovarian  disease.  This  may 
not  appear  very  important  in  each  case 
by  itself,  but  as  the  basis  of  statistical 
information,  it  may  become  of  very  great 
consequence.  Then  we  proceed  to  in- 
vestigate the  early  symptoms  of  the 
disease,  carefully  noting,  on  pages  8  and  9, 
the  first  signs  of  ill-health,  and  a  number 
of  symptoms  Avhich  are  more  or  less  gene- 
rally complained  of,  pretty  much  in  the 
order  in  which  they  are  enumerated  as 
'  Early  Symptoms.' 

The  succeeding  page  contains  a  list  of 
the  symptoms  usually  noticed  as  the  dis- 
ease progresses  either  to  spontaneous  dis- 
charge of  fluid  or  rupture  of  the  cyst,  or 
until  tapping  is  practised  and  repeated,  or 
some  further  treatment  has  to  be  considered. 

A  space  is  left  on  the  next  page  (11) 
Avhere  the  surgeon  should  enter  his  dia- 
gnosis as  fully  as  he  can,  and  then  en- 
deavour to  estimate  the  probable  duration 
of  life  if  palliative  treatment  only  be 
adopted.  A  note  of  the  general  treat- 
ment recommended  may  then  be  made, 
including,  of  course,  such  rules  of  living, 
especially  with  reference  to  air  and  diet, 
clothing  and  exercise,  as  may  be  advised. 
Notes  of  medical  and  surgical  treatment 
follow,  and  in  the  following  page  (12) 
the  progress  of  the  disease  at  subsequent 
visits  may  be  noted  and  marked  on  the 
diagram. 

If  ovariotomy  be  performed,  all  the 
essential  particulars  of  the  operation  may 


SUncaCAL   treatment   of   OVArJAN   TUMOURS 


be    noted   in   the    order  sketched   ia  tlie 
three  succeeding  pages. 

A  page  is  then  left  for  a  description 
of  the  tumour,  and  seven  ruled  pages 
follow  for  the  progress  of  the  patient  after 
operation,  daily  and  hourly  notes  of  tem- 
perature, pulse,  and  respiration,  and  of  any 
medical  or  surgical  treatment.  Another 
page  is  left  for  the  result,  and  a  few  blank 
pages  follow  for  the  subsequent  history. 


It  is  very  desirable  to  ask  every 
patient  who  recovers  to  write,  once  every 
year  on  tlie  anniversary  ot  the  operation, 
giving  full  particulars  as  to  her  state  of 
health — if  unmarried  when  operated  on, 
if  she  has  remained  so,  or  has  married 
since — if  she  has  borne  children,  with 
any  information  as  to  change  of  name  or 
address,  which  may  render  communica- 
tiou  easy  if  desired. 


CHAPTER  III 


TALLIATIYE    AND    MINOR    SUHGICAL    TREATMENT    OF    OVARIAN    TUMOURS 


The  sum  of  doctrine  on  the  medical  treat- 
ment of  ovarian  tumours  amounts  to 
this:  palliate  where  you  can  ;  do  no  mis- 
chief where  you  cannot.  The  state  gf 
health  of  the  patient  is  the  first  con- 
sideration. AW  matters  of  diet,  hygiene, 
tonics  for  the  body,  and  consolation  for  the 
mind,  are  to  be  regulated  and  administered 
under  the  conviction  that  whatever  tends 
to  support  the  strength  and  cheer  the 
spirits  of  the  patient  does  as  much  as  can 
be  done  in  arresting  the  progress  of  a 
disease  Avhich,  in  its  essentially  parasitic 
character,  flourishes  under  despondency 
and  preys  upon  weakness. 

The  local  miseries  which,  we  have  to 
alleviate  mostly  arise  from  pressure  or 
congestion.  The  due  action  of  the  bowels 
and  bladder  is  interfered  with,  the  veins 
are  pressed  upon,  and  oedematous  swell- 
ing of  the  extremities  shows  itself.  The 
area  of  the  chest  is  encroached  upon  and 
breathing  is  made  difficult,  a  teasing  cough 
supervenes,  or  the  heart  is  embarrassed 
and  the  brain  action  enfeebled.  Common 
sense  will  suggest  the  fitting  choice  of 
sedatives  or  stimulants,  aperients  or  enemas, 
the  use  of  the  catheter,  changes  of  posi- 
tion, the  application  of  bandages  or  me- 
chanical supports,  and  the  possibility  of 
relief  sometimes  to  be  obtained  by  manu- 
ally altering  the  position  of  the  tumour 
when  it  is  low  down  or  impacted  in  the 
pelvis. 

Conception  is  a  possibility  which  must 
always  be  borne  in  mind.  It  is  true  that 
pregnancy  may  proceed  to  its  end,  and 
labour  be  accomplished  without  much 
more  than  ordinary  difficulty ;  yet  the 
complication  is  a  cause  of  just  anxiety, 


and  may  give  rise  to  a  state  of  things 
which  renders  the  question  between  pallia- 
tive measures  and  removal  of  the  tumour 
no  longer  one  of  choice. 

But,  independently  of  the  troubles 
incident  to  the  ordinary  course  of  the 
disease,  accidents  will  happen.  The  patient 
may  get  some  local  injury  from  a  blow  or 
a  fall,  or  she  may  be  chilled.  Inflamma- 
tion is  set  up  in  the  tumour  or  in  the 
peritoneal  covering,  and  judicious  treat- 
ment is  called  for.  Absolute  rest, 
fomentations  or  poultices,  and  opium, 
with  or  without  mercury,  must  be  used 
so  as  to  avoid,  if  it  can  any  way  be 
averted,  the  complication  of  pus  forma- 
tion or  plastic  adhesions. 

Many  medicines  have  been  proposed 
for  the  cure  of  ovarian  cysts.  Either  no 
good  has  been  done,  or,  where  benefit  has 
ibllowed  the  use  of  the  remedy,  there  has 
been  a  mistake  in  diagnosis.  So  with  the 
supposed  value  of  drastic  purgatives  and 
hydragogues ;  if  used  Avhen  the  dropsy  is 
ovarian  they  have  often  done  harm,  rarely 
good.  When  they  have  done  good,  fluid 
has  been  free  in  the  peritoneal  cavity  or 
discharged  into  it.  Some  years  ago  I  met 
with  a  curious  illustration  of  this  state- 
ment. I  was  asked  to  see  a  young  lady  in 
consultation  with  Dr.  Headlam  Greenhow, 
who  had  ascertained  the  presence  of  a 
large  single  ovarian  cyst,  and  recommended 
tapping.  Dr.  Marsden  had  ako  seen  the 
patient.  He  believed  the  disease  to  be 
ascites,  said  that  tapping  was  unnecessary, 
and  that  he  could  cure  the  patient  by 
calomel  and  elaterium.  I  quite  agreed 
with  Dr.  Greenhow.  The  danger  of  tap- 
ping seemed  to  me  to  be  very  much  less 


38 


OVAEIAN  AND  ALLIED  TUMOUES 


than  the  danger  either  of  spontaneous 
rupture,  or  of  rupture  accelerated  by 
purging.  This  was  fully  explained  to  the 
friends,  but  they  chose  the  medical  rather 
than  the  surgical  treatment.  It  is  only 
fair  to  the  memory  of  Dr.  Marsden  to  say 
that  his  treatment  was  followed  by  com- 
plete success,  but  I  have  no  doubt  that  a 
thin  cyst  gave  way,  its  contents  escaped 
into  the  peritoneal  cavity,  were  absorbed, 
and  were  carried  off  by  the  watery 
motions  excited  by  the  calomel  and 
elaterium.  Repetition  of  similar  treat- 
ment would  be  followed  by  many  failures. 
I  only  record  the  case  as  a  warning  to 
those  who  would  condemn  such  attempts 
as  invarialjly  useless,  and  to  show  the 
necessity  of  explaining  the  possibility  of 
their  occasional  success. 

Whenever  an  ovarian  cyst  or  tumour 
has  attained  so  large  a  size  that  the  comfort 
and  health  of  the  patient  are  interfered 
with,  it  may  be  taken  as  certain  that 
ordinary  medical  treatment  Avill  be  of 
little  avail.  Any  specific  medical  treat- 
ment by  iodine,  or  bromine,  or  mercury, 
or  gold,  or  arsenic,  or  lime,  or  potash, 
used  with  the  hope  of  checking  the  growth 
of  such  tumours,  must  be  as  useless  as 
any  diuretics  or  other  medicines  expected 
to  lead  to  absorption  of  the  contents  of 
the  cyst;  and  it  would  be  well  if  the 
rule  were  adopted  to  prohibit  any  medical 
treatment  which  could  possibly  injure  the 
health  of  the  patient,  or  place  her  in  a  less 
favourable  condition  than  she  otherwise 
would  be  for  such  surgical  treatment  as 
may  ultimately  be  called  for. 

The  question  when  surgical  aid  really 
is  required,  or  how  long  a  patient  should 
be  left  to  ordinary  medical  care,  undis- 
turbed by  any  .surgical  treatment,  is  one 
which  is  daily  occurring  in  practice,  and 
the  answer  should  be  framed  upon  some 
such  common-sense  rules  as  the  following  : 
so  long  as  the  patient  does  not  suffer  much 
pain,  is  not  annoyed  by  her  size  and 
appearance,  has  no  great  difficulty  in 
locomotion,  and  so  long  as  the  heart  and 
lungs,  digestive  organs,  kidneys,  bladder, 
and  rectum  perform  their  functions 
tolerably  well,  nothing  need  be  done. 
Life  is  not  immediately  threatened,  and 
by  watching  the  advancing  symptoms  the 
moment  for  action  can  almost  always  be 
determined.  But  Avith  the  experience  of 
the  12  years  which  have  elapsed  since 
the  publication  of  my  edition  of  1872,  I 
have  become  more  and  more  disposed  to 


advise  the  removal  of  an  ovarian  tumour 
as  soon  as  its  nature  and  connections  can 
be  clearly  ascertained,  and  it  is  beginning 
in  any  way  physically  or  mentally  to  do 
harm,  since  the  risk  of  the  operation  under 
such  circumstances  is  certainly  less,  and 
the  possible  evils  of  delay  are  eluded. 
Where,  however,  the  distress  of  the 
patient  forces  her  to  demand  some  kind  of 
relief,  and  there  is  either  reluctance  or 
refusal  to  face  the  average  risk  of  exci- 
sion, or  family  considerations  impose  the 
necessity  of  delay,  the  size,  nature,  and 
connections  of  the  tumour  must  guide  us 
in  the  selection  of  one  or  other  of  the 
minor  methods  of  palliative  surgical 
treatment,  which,  though  they  seldom 
lead  to  a  cure,  have  the  advantage  of 
enabling  us  to  alleviate  the  most  distress- 
ing symptoms,  and  to  wait  for  an  oppor- 
tunity to  try  some  of  the  expedients 
adopted  for  the  obliteration  of  the  cyst, 
or  to  carry  out  the  last  resource  of 
ovariotomy. 

These  palliative  measures,  or  substi- 
tutes for  ovariotomy,  may  be  thus  enu- 
merated : 

1.  Simple  tapping  through  the  abdo- 
minal wall. 

2.  Simple  tapping  through  the  vagina. 

3.  Simple  tapping  through  the  rec- 
tum. 

4.  Tapping  followed  by  pressure. 

5.  Tapping  and  the  formation  of  a 
permanent  intra-peritoneal  opening  in  the 
cyst  wall. 

6.  Tapping  and  drainage,  or  the 
formation  of  an  opening  through  the 
abdominal  wall,  the  vagina,  or  the 
rectum. 

7.  Incision. 

8.  Tapping  followed  by  injection  of 
iodine. 

TAPPING 

As  experience  has  increased  and  the 
mortality  after  ovariotomy  has  diminished, 
professional  opinion  has  been  un.settled  as 
to  the  use  or  propriety  of  tapping  ovarian 
cysts.  Some  writers — Stilling,  for  exam- 
ple— have  gone  so  far  as  to  assert  that  it 
is  an  operation  which  ought  to  be  com- 
pletely abandoned.  Few  surgeons  would 
assent  to  this,  but  there  are  many  who 
object  to  tapping  on  two  grounds — first, 
that  it  is  dangerous  in  itself,  and  can  only 
be  of  temporary  utility  ;  and  secondly, 
that  it  is  likely  to  be  followed  by  adhe- 


SURGICAL   TREATMENT   OF  OVARIAN   TUMOURS 


sions  or  other  conditions  which  add 
greatly  to  the  danger  of  subsec^uent 
ovariotomy. 

In  considering  the  objection  to  tapping 
on  the  ground  of  its  danger,  as  compared 
with  the  danger  of  ovariotomy,  some 
Avriters  appear  to  me  to  have  fallen  into 
•error.  They  take  a  certain  number  of 
cases  of  ovarian  disease,  and  say  that  so 
many  patients  died  after  one  tapping,  so 
many  after  five,  six,  or  ten,  and  conclude 
that  tapping  is  a  very  fatal  operation.  I 
have  heard  it  gravely  asserted  that  it  is  a 
more  fatal  operation  than  ovariotomy, 
because  after  ovariotomy  nine-tenths  of 
the  patients  recover,  while  after  tapping, 
sooner  or  later,  they  all  die.  But  the  very 
important  distinction  is  overlooked  be- 
tween an  operation  which  either  cures  or 
kills,  and  one  which  only  fails  to  save  life, 
or  kills  only  under  most  exceptional  cir- 
cumstances. 

It  is  seldom  that  a  surgeon  is  called 
upon  to  perform  ovariotomy  in  order  to 
save  a  patient  from  imminent  death.  But 
this  does  occasionally  happen.  Wiltshire 
published  a  case  where  a  woman,  who 
was  dying  from  bleeding  into  an  ovarian 
cyst,  was  saved  by  immediate  ovariotomy. 
I  have  been  sent  for  twice  to  operate 
under  similar  circumstances,  but  both 
patients  were  dead  before  I  arrived. 
Large  veins  had  burst,  and  some  pounds 
of  blood  were  found  inside  ovarian  cysts. 
If,  in  any  of  these  cases,  the  death  of  the 
patient  had  followed  ovariotomy,  it  could 
hardly  be  said  that  this  operation  had 
killed  the  patient ;  it  had  only  failed  to 
save  life.  So,  if  a  patient  be  near  death, 
either  poisoned  by  an  ovarian  tumour  in  a 
state  of  gangrene  from  twist  in  the  pedicle, 
or  by  the  fetid  contents  of  a  suppurating 
cyst,  or  after  bursting  of  an  ovarian  cyst 
into  the  peritoneal  cavity,  ovariotomy,  if 
performed  unsuccessfully,  may  be  said  to 
fail  in  saving  life — it  cannot  be  said  to 
kill.  Yet  I  have  many  times  operated 
successfully  under  such  desperate  circum- 
stances. In  any  such  case,  ovariotomy 
must  be  compared  with  trephining, 
tracheotomy,  herniotomy,  or  the  ligature 
of  some  large  artery  in  a  case  of  wound 
or  burst  aneurism,  or  primary  amputa- 
tion of  a  limb  in  compound  fracture. 
It  is  not  the  operation  which  is  the  cause 
of  death,  but  the  disease  or  accident  from 
the  effects  of  which  the  patient  is  not 
saved  by  the  operation. 

But  in  the  large  majority  of  cases  of  ■ 


ovariotomy  there  is  as  much  time  for 
discussion  as  in  the  case  of  lithotomy. 
And  in  both  cases  the  responsibility  of 
operating  with  the  full  knowledge  that,  if 
the  patient  be  not  saved  by  the  operation, 
he  or  she  is  killed  by  it,  must  be  fairly 
faced.  It  is  true  that  death  would  almost 
always  be  caused  by  the  stone  or  the 
ovarian  tumour ;  but  it  might  be  at  a 
distant  period,  and  if  death  follow  the 
operation  in  a  few  days^  the  operation 
must  then  be  regarded  as  the  immediate 
cause  of  death. 

Tapping  stands  on  a  totally  different 
ground.  As  a  rule,  when  a  patient  dies 
after  tapping,  it  is  not  that  tapping  has 
hastened  her  death,  but  simply  has  not 
succeeded  in  saving  her  life.  Her  life 
may  have  been  prolonged  by  repeated 
tappings,  but  at  last  she  dies  worn  out  by 
the  disease. 

Tapping  may  be  practised  —  first, 
through  the  abdominal  wall ;  secondly, 
through  the  vagina  ;  and,  thirdly,  through 
the  rectum.  "Whichever  of  these  methods 
may  be  selected,  it  may  be  trusted  to 
alone,  or  it  may  be  followed  by  pressure, 
or  by  the  formation  of  an  opening,  either 
in  the  cyst  wall  only,  with  the  object  of 
establishing  a  communication  with  the 
peritoneal  cavity,  or,  for  drainage,  through 
the  abdominal  Avail,  vagina,  or  rectum. 
In  the  one  case  the  fluid  passes  into  the 
peritoneal  cavity  and  is  absorbed,  no 
external  opening  being  left ;  in  the  other 
a  fistulous  external  opening  is  kept  up 
until  the  cyst  ceases  to  pour  out  fluid  and 
becomes  obliterated.  In  any  of  these 
cases  the  processes  may  be  assisted  by 
pressure ;  and  in  some  tapping  may  be 
followed  by  the  injection  of  iodine. 

TAPPING   THROUGH    THE    ABDOMINAL    WALL 

Avas  formerly  practised  with  the  patient 
sitting  in  a  chair,  a  pail  between  her  legs, 
an  assistant  on  either  side  of  her,  keeping 
a  sheet,  or  long  towels,  so  tightened  round 
the  abdomen  by  pulling  at  the  ends,  that 
the  escape  of  the  fluid  was  supposed  to  be 
assisted,  and  the  fainting  of  the  patient 
prevented.  A  hole  in  the  sheet,  or  a 
space  between  two  towels,  left  room  for 
the  passage  of  the  trocar.  The  operator, 
standing  in  front  of  the  patient,  used  the 
trocar  like  a  dagger,  stabbing  with  con- 
siderable force.  A  good  deal  of  discussion 
arose  at  one  time  as  to  the  propriety  of 
dividing  the  skin  and  fascia  Avith  a  lancet 
before  usina;  the  trocar.     Some  thought  it 


40 


OVARIAN   AND   ALLIED   TUMOURS 


unnecessarily  jovolonged  the  operation, 
others  thought  it  spared  the  patient  the 
shock  and  pain  of  a  forcible  stab.  Any 
way  the  operation  was  a  very  distressing 
one.  The  fainting  of  the  patient  was  by 
no  means  uncommon ;  slie  suffered  from 
exposure  and  shock,  her  clothing  was  often 
wetted  by  the  fluid,  and  she  was  taken 
back  to  bed  frightened,  wet,  cold,  faint, 
and  exhausted.  No  doubt  some  of  the 
dangers  of  tapping  depended  upon  this 
clumsy  method  of  proceeding.  It  is  diffi- 
cult to  understand  otherwise  that  the 
mortality  after  tapping  could  possibly  have 
been  as  high  as  many  writers  have  esti- 
mated it.  Simpson's  calculation  was  that 
the  mortality  after  first  tappings  was  not 
less  than  1  in  G.  Under  the  present 
simplified  mode  of  tapping,  I  very  much 
doubt  if  it  is  as  much  as  1  in  60.  I 
believe  it  has  been  considerably  less  than 
this  in  my  own  experience.  I  have 
removed  115  pints  of  fluid  from  a  patient 
at  one  tapping,  and  121  from  another, 
without  the  slightest  sign  of  faintness, 
without  wetting  either  the  linen  or  the 
bed-clothes,  and  without  disturbing  her 
position  in  the  bed.  I  have  often  re- 
moved 30,  40,  or  50  jiints  of  fluid  from 
patients  reclining  on  one  side  in  bed,  and 
they  have  been  only  conscious  of  the 
relief  afforded  by  the  removal  of  pres- 
sure. They  should  lie  on  one  side  near 
the  edge  of  the  bed,  so  that  the  abdomen 
projects  over  the  edge.  As  a  rule, 
the  linea  alba  is  the  preferable  site  for 
puncture,  but  any  hard  portions  of  the 
tumour  should  be  avoided,  and  the  most 
elastic  or  distinctly  fluctuating  points  of  \ 
the  tumour  selected.  Before  puncturing, 
great  care  should  be  taken  by  palpation 
and  percussion  to  ascertain  that  no  intes- 
tine is  lying,  or  adhering,  between  the 
cyst  and  the  abdominal  wall,  at  the  point 
selected  for  tapping ;  and  any  visible 
superficial  veins  should  be  avoided.  It  is 
certainly  advantageous  to  puncture  the 
skin  with  a  lancet  before  using  the  trocar, 
and  if  the  patient  is  very  sensitive  to  pain 
the  seat  of  puncture  may  be  frozen  by 
ether  spray.  And  every  now  and  then 
with  a  very  nervous  subject,  or  where  the 
excessive  accumulation  of  fat  on  the  abdo- 
men  gives  a  formidable  look  to  the  pro- 
ceedings, and  may  perhaps  occasion  some 
little  difficulty  in  driving  the  canula  to  its 
destination,  it  may  be  as  well  to  adminis- 
ter a  slight  amount  of  some  anassthetic  so 
as  to  calm  the  timidity,  or  give  the  opera- 


tor the  opportunity  of  doing  what  he  has 
to  do  with  greater  facility. 

The  condition  of  the  cyst  wall  may 
also  be  the  cause  of  embarrassment  or 
danger  in  tapping.  I  have  many  times 
observed  it  so  far  gone  in  degenerative 
changes  as  to  make  it  friable  ;  and  though 
it  has  been  kept  entire  by  the  equable 
support  of  the  surrounding  parts,  any 
essays  to  puncture  with  a  trocar  must 
have  crushed  it  and  caused  the  discharge 
of  the  contents.  In  at  least  3  operations 
whore  I  came  upon  fluid  free  in  the 
peritoneum,  on  examining  the  cyst,,  the 
hole  made  in  a  previous  tapping  was 
quite  open,  a  piece  of  inelastic  matter 
having  been  forced  away  so  that  there 
Avas  no  possibility  of  closing.  There  have 
been,  too,  some  examples  of  bony  deposit 
in  the  tissue  sufficiently  hard  to  turn  the 
point  of  a  trocar.  Ritchie  reported  of 
one  of  my  cases,  a  partial  thickness  of  2 
inches,  enough  to  arrest  any  ordinary 
operator  under  the  impression  that  he 
had  come  in  contact  with  a  solid  fibroid. 
In  other  multilocular  cysts  one  compart- 
ment may  have  walls  of  almost  impene- 
trable solidity,  and  an  adjoining  one  of 
not  more  than  a  line  in  thickness,  so  that 
a  first  attempt  to  draw  off  fluid  may  be 
an  utter  failure  and  lead  to  an  erroneous 
conclusion,  Avhile  the  next,  from  shifting 
of  the  position  of  the  mass  or  change  of 
point  of  puncture,  may  fall  upon  a  thin 
loculus,  give  vent  to  the  contents,  and 
alter  the  diagnosis  completely. 

The  trocar  has  been  greatly  improved: 
of  late  years.  The  old  instrument  was  so 
short  that,  if  the  abdominal  Avail  Avas  thick, 
the  trocar  never  reached  the  cyst,  or  it 
may  just  have  punctured  the  cyst,  and  the 
canula  Avas  too  short  to  folloAv  it.  In  the 
first  case  no  good,  but  no  harm,  Avas  done; 
in  the  second  the  results  were  dangerous 
or  fatal.  The  punctured  cyst  poured  out 
its  contents  into  the  peritoneal  cavity,  and 
dangerous  symptoms  or  death  followed,, 
the  danger  arising  not  from  the  tapping, 
but  from  the  bad  Avay  in  which  it  Avas 
done. 

Great  difference  of  opinion  has  been 
expressed  as  to  the  effect  of  admitting  air 
into  an  ovarian  cyst  Avhile  the  fluid  iii 
escaping.  Some  Avriters  h.ave  argued  that 
it  can  do  no  harm.  My  OAvn  opinion, 
founded  upon  the  few  cases  where  I  have 
been  sure  that  air  has  entered,  is  in  accord- 
ance with  those  who  assert  it  to  be  fre- 
quently folloAved   by   cyst  inflammation, 


SURGICAIi   TREATMENT   OF  OVARIAN  TUMOURS. 


41 


by  fever,  and  by  decomposition  of  the 
fluid  which  remains  in  the  cyst,  or  is 
secreted  soon  after  the  tapping.  I  there- 
fore regard  the  improvement  in  the  trocar 
■which  provides  against  the  entrance  of 
air  into  the  cyst  during  the  escape  of  fluid 
as  an  important  element  in  the  diminution 
of  the  mortality  after  tapping.  We  are 
indebted  to  Mr.  Charles  Thompson  for 
introducing  one  of  the  first  instruments 
by  which  this  object  has  been  attained. 
In  his  own  words,  '  It  consists  of  a  cylin- 
drical silver  canula  about  4  inches  long, 
into  which  opens  at  near  its  middle  a 
short  silver  conducting  tube  of  the  same 


calibre,  to  which  a  piece  of  india-rubber 
tubing  about  a  foot  long  is  attached  by  a 
screw.     In  this  canula  plays  a  solid  steel 


^=TI^ 

piston,  with  a  trocar  point,  its  body  being- 
of  such  length  that,  when  fully  pushed 
forward,  as  in  the  above  figure,  its  point 
protrudes  sufficiently  from  the  canula,  and 
its  other  extremity  seals  the  entrance  of 
the  conducting  tube;  and,  when  fully 
withdrawn,  as  in  this  fio-ure — 


it  retires  so  far  as  to  open  the  conducting 
tube.  This  piston  must  fit  the  canula  so 
])erfectly  as  to  be  air-tight  when  greased. 
The  little  cap  of  the  canula  unscrews  to 
admit  of  the  removal  of  the  piston  for 
greasing  or  cleaning.  The  outer  half  of 
the  canula  is  mounted  in  a  solid  wooden 
handle  to  give  a  firm  grasp  of  the  instru- 
ment.' 

As  soon  as  I  read  this  description  of 
Thompson's  trocar,  I  saw  how  useful  it 
would  be,  both  in  tapping  ovarian  cysts 
and  in  ovariotomy,  and  I  had  instruments 
made  with  canulas  of  different  lengths 
and  calibre,  suitable  for  both  purposes, 
and  continued  to  use  them  for  some 
months.  I  found  that  admission  of  air 
was  prevented,  the  syphon  action  assisting 
in  keeping  up  a  continuous  flow  of  fluid, 
while  the  escape  could  be  stopped  at  any 
desirable  moment.  If  the  tube  or  canula 
became  blocked  it  was  easily  cleared. 
The  fluid  was  conveyed  into  the  re- 
ceiving vessel,  while  the  patient  was  kept 
perfectly  dry,  not  alarmed  by  the  splash- 
ing of  the  fluid,  and  not  disturbed  by  the 
changing  of  the  basins,  which  was  so 
troublesome  when  the  old  instrument  was 
used. 
*"  While  still  desirous  to  carry  on  the 
principle  of  the  syphon,  as  adapted  to  the 
trocar,  I  became  anxious  to  avoid  the 
momentary  delay  between  the  introduc- 
tion of  the  trocar  and  the  escape  of  the 
fluid,  while  the  piston  was  being  with- 
drawn. I  was  led  to  this  by  observing 
that,  when  using  the  large-sized  instru- 


ment in  ovariotomy,  there  was  sometimes 
a  rush  of  fluid  between  the  cyst  and  the 
outside  of  the  canula  before  the  piston 
could  be  withdrawn,  and  it  was  evident 
that  the  same  thing  might  occur  during: 
ordinary  tapping.  After  two  or  three 
trials,  it  occurred  to  me  that  a  hollow 
piston,  something  like  a  steel  pen  slidingr 
in  the  pencil-cases  in  ordinary  use,  might 
be  a  convenient  mode  of  effecting  the 
object  in  view.  I  first  carried  out  thi& 
idea  in  an  instrument  of  the  size  for 
ovariotomy,  adding,  to  the  outside  of  the 
canula,  grooves  upon  which  the  cyst  could 
be  tied  as  it  became  lax.  Modifications 
which  I  have  since  made  in  this  instru- 
ment are  described  in  the  chapter  on 
Ovariotomy.  When  the  instrument  is- 
made  of  the  size  for  simple  tapping,  the 
canula  is  perfectly  smooth.  A  lancet 
puncture  is  made  through  the  skin,  andl 
the  instrument  is  then  easily  thrust  into 
the  cyst.  Fluid  escapes  immediately,  and 
the  point  is  withdrawn  to  prevent  injury 
to  the  cyst  as  it  contracts.  It  is  impor- 
tant that  the  edges  of  the  canula  should 
not  be  thin,  but  perfectly  smooth  and  well 
rounded  off.  There  would  otherwise  be 
danger  of  injury  to  large  veins  on  the 
inner  surface  of  the  cyst ;  and  the  maker 
should  be  careful,  in  sharpening  the  cutting 
end  of  the  hollow  trocar,  to  leave  one  half 
of  the  lips  quite  blunt.  If  sharpened  all 
round  it  would  act  as  a  punch,  and  cut  a 
circular  hole  in  the  skin.  I  have  seen  a 
tube  blocked  in  this  Avay,  and  more  than 
once  a  round  piece  of  skin  floating  in  tlae 


42 


OVARIAN   AND   ALLIED   TUMOUES 


fluid,  or  so  nearly  detached  after  the  canula 
was  withdrawn  that  it  was  better  to  cut 
it  awav.  If  the  instrument  is  properly 
finished,  only  a  semilunar  cut  is  made  in 
the  skin  and  cyst,  which  closes  much  more 
readily  than  the  triangular  puncture  made 
by  the  old  trocar. 

Instead  of  the  india-rubber  tube,  it  is 
quite  easy  to  fix  to  the  end  of  the  canula 
an  ordinary  india-rubber  enema  syringe, 
by  which  more  powerful  exhausting  suc- 
tion can  be  brought  to  bear  upon  the  j 
contents  of  the  cyst  than  can  be  obtained  I 
by  the  syphon  tube;  and  if  it  be  desirable 
to  wash  out  the  cyst,  or  to  inject  iodine 
or  any  other  antiseptic  into  it,  this  can  be 
readily  done  by  reversing  the  syringe 
without  removing  the  canula. 

When  using  this  syphon  trocar,  care 
should  be  taken  so  to  introduce  the  instru- 
ment that  the  point  passes  into  the  fluid 
at  a  lower  level  than  at  the  commence- 
ment of  the  tube,  as  shown  in  the  sketch. 


Air  will  not  descend  except  under  strong 
suction,  or  into  a  vacuum,  and  there  is 
no  fear  of  air  passing  up  the  tube  and 
down  the  canula  into  the  cyst.  The 
instant  the  canula  enters  the  cyst,  fluid 
rushes  into  it,  pressing  the  air  before  it, 
and  if  the  tube  be  properly  mounted  so 
that  it  does  not  bend  or  narrow  the  canal, 
the  tube,  which  should  be  about  three 
feet  long,  at  once  becomes  the  long  arm 
of  a  syphon.  The  atmospheric  pressure 
and  syphon  action  of  this  long  column  of 
fluid  are  so  great,  that  the  air  can  be 
heard  bubbling  into  the  tube  through 
the  well-fitting  bayonet  joint  provided 
for  the  Avithdrawal  of  the  point  of  the 
instrument.  It  is  better  to  keep  the 
end  of  the  tube  under  the  fluid  when 
the  cyst  is  nearly  empty,  to  avoid  any 
accidental  drawing  inwards  of  air  as  a 
patient  makes  some  deep  inspiration  or 


expiration,  leading  to  a  kind  of  vacuum 
within  the  abdomen.  In  withdrawing 
the  instrument  it  is  always  well  to  press 
the  abdominal  wall  close  down  i;pon  the 
cyst,  and  with  the  finger  and  thumb  of 
the  other  hand  so  to  hold  the  abdominal 
walls  together  behind  the  escaping  canula 
as  to  prevent  any  entrance  of  air. 

Instead  of  the  syphon -trocar  some 
surgeons  have  used  aspirators  of  different 
sizes  and  modifications.  But  they  are  all 
open  to  the  objection  that  as  the  cyst 
becomes  empty  its  flaccid  walls  are  sucked 
into  the  end  of  the  canula  and  stop  the 
flow  of  fluid. 

Should  any  bleeding  follow  the  re- 
moval of  the  instrument  and  not  be 
stopped  by  a  little  pressure,  a  hare-lip  pin 
may  be  passed  completely  across  the 
opening,  deeply  enough  beneath  the  skin 
to  compress  any  injured  vessel.  Two  or 
three  turns  of  silk  twisted  round  the  pin 
make  sufficient  pressure  to  stop  any 
bleeding.  It  will  not  do  simply  to  bring 
the  edges  of  the  skin  together  with  a  pin; 
this  might  only  conceal  dangerous  internal 
bleeding.  In  some  cases  internal  haemor- 
rhage, even  fatal,  has  followed  the  punc- 
ture, and  this  may  be  explained  either  by 
the  opening  of  varicose  vessels  in  the  cyst 
wall,  where  they  sometimes  attain  enor- 
mous development,  or  by  the  presence  of 
such  enlarged  veins  in  the  omentum  as 
were  found  in  the  examination  of  the 
woman  operated  on  as  my  731st  case, 
Avhere  the  size  was  such  as  to  have  made 
the  suppression  of  bleeding  impossible 
without  immediate  laparotomy.  One  of 
my  neighbours  lost  a  case  within  a  few 
hours  after  tapping ;  upwards  of  five 
pints  of  blood,  Avhich  had  escaped  from  a 
varicose  vein,  having  been  found  in  the 
peritoneal  cavity.  The  vein  ran  directly 
in  front  of  the  peritoneum,  immediately 
beneath  the  linea  alba,  from  the  umbili- 
cus towards  the  liver.  A  pin  through 
the  whole  thickness  of  the  abdominal 
wall  would  have  compressed  this  vessel. 

Whenever  it  is  doubtful  if  a  cyst  has 
been  completely  emptied,  or  there  is  some 
escape  of  fluid  after  the  removal  of  the 
trocar,  the  comfort  of  the  patient  is  greatly 
increased  by  closing  the  opening  with  a 
hare-lip  pin  and  twisted  suture,  but  the 
pin  need  not  be  passed  so  deeply  as  in  case 
of  bleeding.  I  was  led  to  adopt  this 
practice  from  the  remark  made  to  me  by 
Mr.  Ca'sar  Hawkins  upon  a  case  where 
oozing  after  tapping  Avas  going  on.     He 


SURGICAL   TREATMENT   OF  OVARIAN   TUMOURS 


43 


said,  '  When  tliey  ooze  they  always  die,' 
so  I  determined  tliat  they  should  not  ooze 
imless  I  wished  to  drain.  In  ordinary 
cases  a  pin  is  not  necessary,  a  small  pad 
of  lint  and  a  strip  of  adhesive  plaster 
being  quite  suOicient  to  cover  the  open- 
ing. The  abdomen  should  be  supported 
by  an  ordinary  binder. 

In  order  to  prove  that  simple  tapping 
throujrh  the  abdominal  Avail  is  occasion- 
ally foUoAved  by  a  radical  cure,  I  can 
refer  to  many  cases  in  my  note-books. 
Sometimes  it  has  been  necessary  to  empty 
the  cyst  a  second  time  ;  and,  contrary  to 
expectation,  there  Avas  no  return  of  filling 
in  one  case  Avhere  I  had  drawn  off  fluid 
dark  brown  in  colour  and  rather  viscid. 
Some  of  the  earlier  patients  remained 
under  observation  for  many  years  alter 
the  operation.  For  the  most  part  they 
kept  in  good  health  ;  a  fcAV  died  of  other 
diseases,  Avhile  others  married  and  had 
children.  lu  one  case  I  tapped  the 
patient  only  the  day  before  she  was 
married.  She  became  pregnant  at  once, 
and  has  had  several  children  since,  Avith- 
out  any  refilling  of  the  cyst. 

My  experience  accords  Avith  the  con- 
clusions draAvn  by  Dr.  Mehu  from  his 
researches  on  the  abundant  material  sup- 
plied to  him  by  the  hospitals  and  ])racti- 
tioners  of  Paris,  that  in  spite  of  a  fcAv 
exceptional  cases,  it  is  only  when  single, 
and  probably  broad-ligament  or  extra- 
peritoneal cysts,  are  tapped,  and  clear, 
non-albuminous  fluids  are  evacuated, 
there  is  a  reasonable  hope  of  fluid  not 
iigain  accumulating. 

In  order  to  Aveigh  the  value  of  the 
A'arious  objections  to  tapping,  I  have  gone 
over  the  records  of  my  first  500  cases  of 
ovariotomy.  265  of  these  500  patients 
had  been  tapped  previously,  from  1  to 
18  times.  193  of  these  tapped  patients 
recovered,  and  72  died,  giving  a  mortality 
of  27*16  per  cent. 

The  general  mortality  of  the  500  cases 
was  25*4  per  cent.,  and  235  patients,  or 
nearly  one-half,  had  never  been  tapped. 
In  them  the  mortality  was  23*4  per  cent., 
just  2  per  cent,  less  than  the  general  mor- 
tality. In  other  Avords,  the  mere  fact  that 
a  patient  has  or  has  not  been  tapped  (so 
far  as  can  be  judged  from  500  cases  in 
the  hands  of  the  same  operator)  does  not 
aifect  the  result  of  the  operation  by  more 
than  2  per  cent.  Indeed,  the  mortality 
of  the  patients  not  tapped,  though  less 
by  about    10  per  cent,  than  that  of  the 


patients  avIio  had  been  tapped  tAvice,  is 
greater  than  that  of  the  patients  Avho  liad 
been  tapped  once  and  three  times.  Thus 
140 — or  rather  more  than  one-fourth — 
had  been  tapped  once,  and  the  mortality 
Avas  23  57  per  cent.  Of  32  Avho  Avere 
tapped  three  times,  tlie  mortality  was 
2l"87  per  cent.  Of  the  49  Avho  Avere 
tapped  twice,  the  mortality  Avas  nearly  the 
same  as  tliat  of  the  group  of  cases  tapped 
from  4  to  18  times,  namely  3 4' 6 9  per 
cent.,  or  about  1  in  3. 

An  investigation  of  the  details  of  sub- 
sequent cases  confirms  the  impression  that 
the  mortality  of  ovariotomy  is  but  little 
affected  by  previous  tapping.  The  fact 
of  a  patient  not  having  been  tapped,  or 
having  been  tapped  very  often,  is  by  itself 
of  little  or  no  value  in  prognosis.  I  have 
stated  elsewhere  that  such  adhesions  as 
are  apt  to  foUoAv  tapping  do  not  greatly 
increase  the  mortality  after  ovariotomy ; 
and  I  can  noAV  add  that  in  some  of  the 
patients  Avho  have  been  tapped  most  fre- 
quently there  Avere  no  adhesions,  and 
there  Avere  firm  adhesions  in  some  Avho 
had  never  been  tapped. 

Although  more  impressed  of  late  years 
by  the  danger  of  putrefactive  changes  in 
the  fluid  after  tapping  Avithout  antiseptic 
precautions,  I  still  adhere  to  the  folloAving 
propositions : 

1.  That  in  cases  of  simple  ovarian  or 
extra-OA'arian  cysts,  it  is  right  to  try  the 
effect  of  one  tapping  before  advising  a 
patient  to  undej-go  a  more  serious  risk. 
But  in  compound  or  multilocular  cysts 
the  third  proposition  holds  good. 

2.  That  one  or  many  tappings  do  not 
increase  considerably  the  mortality  of 
ovariotomy. 

3.  That  tapping  may  sometimes  be  a 
useful  prelude  to  ovariotomy,  either  as  a 
means  of  gaining  time  for  a  patient's 
general  health  to  recover — of  clearing  the 
urine  of  the  albumen  Avith  Avhich  it  is 
sometimes  charged  under  the  mere  influ- 
ence of  pressure — or  of  lessening  shock, 
by  relieving  her  of  the  fluid  a  feAv  hours 
or  days  before  removing  the  solid  portion 
of  an  ovarian  cyst ;   and 

4.  That  when  the  syphon- trocar,  Avhich 
I  brought  before  the  profession  in  1860, 
is  carefully  used  [in  such  a  manner  as  to 
prevent  the  escape  of  OA'arian  fluid  into 
the  peritoneal  cavity,  and  the  entrance  of 
air  or  of  putrefactive  material  into  the 
cyst,  the  danger  of  tapping  is  extremely 
small. 


44 


OVARIAN   AND   ALLIED   TUMOURS 


TAPPING    THROUGH    THE    VAGINA 

is  more  liable  to  be  followed  by  inflamma- 
tion of  the  cyst  than  tapping  through  the 
abdominal  wall,  because  it  is  not  easy  to 
prevent  the  entrance  of  air.  We  should 
always  endeavour  to  avoid  this  accident 
by  attention  to  the  level  of  the  cauula, 
but  the  attempt  does  not  invariably 
svicceed.  The  operation  of  tapping 
through  the  vagina  is  selected  not  so 
much  with  the  intention  of  simply  empty- 
ing the  cyst,  as  for  the  chance  that,  should 
the  fluid  escape  by  the  opening  as  fast 
as  it  is  secreted,  the  cyst  may  gradually 
contract  and  the  puncture  close.  This 
favourable  result,  however,  is  seldom 
secured.  As  a  rule,  air  enters  the  cyst, 
the  opening  fills  up,  and  the  fluid  remain- 
ing in  the  cyst,  or  that  freshly  secreted, 
putrefies.  Suppurative  inflammation  of 
the  lining  membrane  of  the  cyst  comes 
on,  and  is  accompanied  by  a  low  form  of 
septic  fever  or  pytemia,  which  can  only  be 
relieved  by  maintaining  a  free  outlet  for 


the  discharge.  The  frequency  of  these 
consequences  should  make  tapping  through 
the  vagina  an  exceptional  practice.  But 
it  may  be  adopted  in  cases  where  an 
ovarian  cyst  is  bound  down  in  the  pelvis 
by  adhesions,  and  it  is  necessary  to  relieve 
the  distress  caused  by  pressure  on  the 
bladder  and  rectum.  The  puncture  should 
then  be  made  where  the  fluctuation  is 
most  evident,  but  as  near  the  median 
line  as  possible.  The  canula,  or  an  elastic 
catlieter,  may  be  left  in  the  cyst,  though 
it  is  safer  practice  either  to  introduce  a 
wire  seton,  or  a  drainage  tube,  so  as  to 
prevent  the  opening  from  closing,  and 
make  sure  of  the  free  and  immediate 
escape  of  any  fluid  that  may  be  secreted. 
Whether  a  canula  or  tube  be  used,  it  is 
necessary  to  adopt  some  contrivance  to 
prevent  it  from  slipping  out ;  and  I  find 
a  piece  of  wire  doubled  at  the  inner  end 
answers  this  purpose  well.  The  ends 
open  out,  as  shown  in  this  drawing,  and 
maintain  either  canula  or  tube  in  the 
cavity  until  the  Avire  is  withdrawn. 


It  is  now  about  20  years  since  I 
treated  a  case  of  ovarian  dropsy  in  this 
way.  This  shows  my  reluctance  to  face 
the  risks  incurred  by  it.  Though  none  of 
my  early  cases  had  an  immediately  fatal 
result,  and  two  of  them  were  followed  by 
restoration  to  perfect  health,  the  others 
died  within  a  few  years,  either  from 
exhaustion  by  the  continuous  discharge, 
or  from  recurring  suppuration. 

It  must  always  be  borne  in  mind  that, 
to  carry  out  this  practice  with  any  chance 
of  success,  the  opening,  Avhich  is  not 
merely  for  evacuation,  but  drainage,  must 
be  free  and  well  placed,  so  as  to  avoid  the 
possiVjility  of  any  accumulation.  The 
utmost  cleanliness  must  be  observed, 
injections  of  sulphurous  acid,  or  some 
other  disinfectant,  are  incessantly  re- 
quired ;  and  everything  must  be  done  to 
promote  the  health  of  the  patient. 

The  impression  left  on  my  mind  by 
what  I  have  seen  of  vaginal  tapping, 
leads   me  to    the  conclusion  that  simple 


tapping  is  more  hazardous  than  tapping 
followed  by  drainage,  and  that  drainage 
should  be  so  complete  that  no  reaccumula- 
tion  of  fluid  can  take  place,  the  cavity 
being  kept  open  until  its  walls  collapse  and 
imite,  so  that  it  is  completely  obliterated. 
Even  then,  patients  are  so  apt  to  suffer 
from  some  of  the  ill  effects  of  long-con- 
tinued suppurative  processes,  that  I  am 
more  than  ever  confirmed  in  the  opinion 
that  it  is  better,  even  at  considerable  risk, 
to  remove  a  cyst,  if  at  all  possible,  than 
to  trust  to  any  mode  of  drainage. 

TAPPING    TIinOUGII    THE    liECTl'M 

has  been  supposed  to  possess  some  advan- 
tages over  tapping  through  the  vagina. 
It  was  said  that  there  would  be  no  con- 
stant discharge  of  offensive  fluid,  for  any 
ovarian  fluid  Avhich  entered  the  rectum 
would  be  retained,  just  as  a  liquid  motion 
is  retained  by  the  sphincter  aui,  and  dis- 
charged when  the  patient  pleased.  But  a 
dysenteric  tenesmus  has  been  occasionally 


SURGICAL  TREATMEIsT  OF  OVARIAN  TUMOURS 


observed,  which  has  proved  very  distress- 
ing. It  was  supposed  that  the  objection 
to  vaginal  tapping  fiom  entrance  of  air 
into  the  cyst  would  be  guarded  against  in 
rectal  tapping  by  the  contraction  of  the 
sphincter  ani.  But  the  entrance  of  fa3cal 
gas  into  a  cyst  would  be  quite  as  likely  to 
occur,  and  would  be  more  injurious  than 
the  entrance  of  atmospheric  air  in  vaginal 
tapping.  Fatal  inflammation  has  followed 
the  entrance  of  faecal  gases  into  the  cyst. 
I  had  one  such  case  with  Dr.  Priestley. 
We  tapped  an  adhering  cyst  through  the 
rectum,  and  the  patient  died  some  days 
afterwards  of  cyst  inflammation.  The 
cavity  was  filled  with  faecal  gas. 

INJECTION   OF    IODINE 

Notwithstanding  the  advocacy  of 
Boinet,  the  practice  of  injecting  ovarian 
cysts  with  iodine  has  quite  fallen  into 
discredit ;  and,  so  far  as  my  own  trials 
and  means  of  observation  enable  me  to 
judge,  not  in  any  way  to  the  disadvantage 
of  patients.  The  few  cysts  which  I  in- 
jected and  which  did  not  refill  for  several 
years  were  single,  with  limpid  contents, 
and  in  such  cysts  I  believe  tapping  is  as 
effectual  alone  as  it  is  with  the  injection 
of  iodine  in  addition. 

The  only  cases  in  which  iodine  injec- 
tion is  really  useful,  and  where  its  employ- 
ment should  be  recommended,  are  those  in 
which,  after  tapping  either  by  the  abdo- 
minal wall,  vagina,  or  rectum,  cyst  inflam- 
mation has  occurred,  and  the  patient  is 
suffering  from  absorption  of  the  decom- 
posing contents  of  the  cyst.  Here  free 
drainage  becomes  necessary  to  save  the 
patient  from  pya?mia  or  septicaemia ;  but 
•she  may  suffer  considerably  in  appetite 
and  strength  if  the  fluid  which  escapes  is 
offensive;  and  it  ought  to  be  deodorised. 
For  this  purpose  iodine,  or  phenol,  or  sul- 
phurous acid,  or  chromic  acid  may  be 
tised  in  tolerably  strong  solution;  and 
iodine  I  used  to  think  preferable  to  all 
the  others.  A  solution  of  1  part  of  iodine 
and  2  of  iodide  of  potassium  to  20 
parts  of  water  was  used  night  and  morn- 
ing, injected  through  the  catheter  after 
washing  out  the  cyst  with  warm  water ; 
and  the  greater  part  of  the  iodine  solution 
injected  was  allowed  to  run  away  again  at 
once.  But  a  little  was  left  in  the  cyst, 
partly  to  act  on  its  walls  and  partly  to 
deodorise  the  fluid  contents  of  the  cyst  if 
they  putrefied.  Latterly  I  have  had 
reason  to  prefer  sulphurous  acid  to  iodine. 


I  have  used  with  excellent  effect  a  mixture 
of  one  part  of  the  acid  of  the  British 
Pharmacopccia  with  G  or  8  parts  of  tepid 
water. 

XnEATMENT    I!Y    INCISION 

The  practice  of  laying  open  ovarian 
cysts  by  incision  no  doubt  arose  when, 
during  tapping,  the  instrument  used 
proved  to  be  too  small  for  the  escape  of 
thick  fluid.  On  withdrawing  the  canula 
it  would  be  found  filled  with  glue-like 
matter,  and  similar  matter  would  be  ob- 
served exuding  from  the  opening.  The 
natural  result  would  be  that  the  surgeon 
would  enlarge  the  opening,  until  the  con- 
tents of  the  cyst  could  escape  or  be 
squeezed  out.  This  has  occurred  to  me 
more  than  once.  I  was  present  when  Mr. 
Armstrong  Todd  tapped  a  young  lady. 
After  a  little  fluid  had  escaped,  the  canula 
became  clogged  with  hair  and  fat,  and  it 
was  withdrawn.  Fluid  continuing  to  ooze 
away,  the  opening  was  enlarged  until  first 
one  finger,  then  two,  and  then  a  tablespoon 
could  be  used  to  scoop  out  many  pounds 
of  semi-solid  fat,  with  masses  of  hair  and 
bony  spiculee,  from  a  cyst  which  Avas  inti- 
mately adhering  over  a  large  extent  of  the 
abdomen.  Ovariotomy  was  proposed  to 
the  parents,  but  they  preferred  the  alterna- 
tive of  drainage,  and  the  patient  only  sur- 
vived a  few  days. 

In  another  case,  where  the  contents  of 
a  large  cyst  consisted  of  colloid,  I  made 
an  incision  2  inches  long,  and  squeezed 
out  many  pounds  of  matter.  In  this  case 
relief  was  given  for  a  time,  but  the  patient 
ultimately  died  exhausted  from  the  con- 
tinuous discharge. 

In  the  cases  hereafter  described,  where 
it  has  been  impossible  to  complete  ova- 
riotomy, and  the  cyst,  or  a  portion  of  it, 
has  been  left  Avithin  the  abdominal  cavity, 
the  edges  of  the  opening  in  the  cyst  have 
been  fixed  to  the  abdominal  Avail  by 
suttire,  and  such  cases  have  become  simi- 
lar to  those  treated  by  incision.  I  have 
not  adopted  the  practice  of  incision  tinder 
any  other  circumstances,  but  it  has  been 
repeatedly  done  by  others,  and  A-arious 
means  have  been  taken  to  preA'-ent  the 
escape  of  the  fluid  into  the  abdominal 
cavity.  Adhesion  betAveen  the  cyst  and 
the  abdominal  wall  has  been  secured  by 
caustic  issues,  or  by  the  insertion  of 
needles,  or  by  the  use  of  special  instru- 
ments, or  by  suture  after  laying  bare  the 
cyst.     As  soon  as  adhesion  Avas  believed 


46 


OVARIAN  AND   ALLIED   TUMOURS 


to  be  complete,  the  incision  was  made, 
and  the  cyst  kept  open  until  the  oblitera- 
tion of  its  cavity  took  place.  So  far  as  I 
can  learn,  from  my  own  experience  and 
the  study  of  recorded  cases,  this  practice 
is  far  more  dangerous  than  ovariotomy, 
and  very  much  less  likely  to  be  followed 
by  complete  cure.  I  think,  therefore,  it 
should  only  be  considered  admissible  in 


cases  where  ovariotomy  cannot  be  com- 
pleted. Then  after  incision  and  emptying 
the  cyst  as  far  as  possible,  and  securing 
the  opening  in  the  cyst  to  the  opening  in 
the  abdominal  wall,  the  cavity  is  kept 
empty  by  draining  and  the  injection  of 
disinfecting  or  deodorising  agents.  The 
conditions  are  then  the  same  as  those  of  a 
drained  abscess. 


CHAPTER   IV 


THE    RISE    AND    PROGRESS    OF    OVARIOTOMY 


Ovariotomy.  From  wapior,  ovary ;  and 
7o;i»'/,  incision,  [Syn.  Ovariotomie,  Fr. 
and  Ger. — Ovariotomia,  Ital.  and  Sp.] 
Ovariotomy,  as  performed  by  surgeons 
when  one  or  both  ovaries  are  diseased,  is 
a  very  different  proceeding  from  the  ex- 
tirpation of  healthy  ovaries,  which  .  has 
been  practised  from  remote  antiquity  on 
domestic  animals  for  economical  purposes, 
and  both  in  ancient  periods  and  in  the 
Middle  Ages  on  Avomen,  almost  exclusively 
for  immoral  purposes. 

At  the  present  day  it  seems  to  be  a 
common  practice  among  some  of  the 
natives  at  the  antipodes.  Dr.  Junker 
reports  that  the  aborigines  of  Australia 
and  of  New  Zealand  perform  ovariotomy 
on  young  girls  by  incision  in  both  in- 
guinal regions.  They  do  this  for  two 
purposes  :  to  prevent  the  propagation  of 
hereditary  diseases  and  deformities  and 
other  disabilities,  and  to  keep  up  a  supply 
of  barren  prostitutes. 

It  was  not  earlier  than  in  the  17th 
and  1 8th  centuries  that  ovariotomy  was 
proposed  and  suggested  as  a  radical 
cure  for  diseased  ovaries.  As  late  as 
the  beginning  of  the  18th  century 
thi.s  operation  was  first  performed,  and 
it  remained  long  in  discredit.  It  is 
only  within  the  last  30  years  that  it 
has  been  at  all  frequently  or  generally 
practised. 

The  subject  began  to  be  discussed 
by  surgical  writers  in  the  17th  cen- 
tury. But  they  got  no  farther  than  an 
expression  of  belief  that  extirpation  of 
dropsical  ovaries,  if  it  could  be  done, 
would  lead  to  a  permanent  cure  of  the 
disease.  In  the  first  50  years  of  the 
next  century  the  operation  was  not  only 


admitted  to  be  possible,  but  was  recom- 
mended, though  with  so  many  qualifying 
conditions  that  no  one  did  it.  Some 
authorities,  such  as  De  Haen  and  Mor- 
gagni,  opposed  it  altogether,  while  a  few 
more  sanguine  prophesied  its  ultimate 
success.  Later  on,  in  our  own  country, 
the  Hunters  took  up  the  question. 

Dr.  William  Hunter,  in  a  paper  *  On 
Cellular  Tissue,'  pviblished  in  17G2,  says: 
'  It  has  been  proposed  by  modern  sur- 
geons, deservedly  of  the  first  reputation, 
to  attempt  a  radical  cure  by  incision  or 
suppuration,  or  by  excision  of  the  cyst.' 
Having  pointed  out  difliculties  during 
the  operation,  and  dangers  following  it, 
in  support  of  his  opinion  *  that  incision 
can  hardly  be  attempted,'  he  concludes 
with  the  following  words,  which  fore- 
shadow some  of  the  recent  modifications 
in  the  operation  :  *  If  it  be  proposed, 
indeed,  to  make  such  a  Avound  in  the 
belly  as  will  admit  two  fimjers  or  so,  and 
then  tap  the  bag  and  draio  it  out,  so  as  to 
bring  its  root  or  peduncle  close  to  the 
wound  of  the  belhj,  that  the  surgeon  may 
cut  it  Avithout  introducing  his  hand,  surd// 
in  a  case  otherivise  so  desperate  it  viiijht 
be  advisable  to  do  it,  could  Ave  beforehand 
knoAv  that  the  circumstances  would  admit 
such  treatment.'     {Op.  cit.  p.  45.) 

In  a  lecture  delivered  in  1785,  John 
Hunter  has  this  passage  :  *  I  cannot  see 
any  reason  Avhy,  Avhen  the  disease  can  be 
ascertained  in  an  early  stage,  Ave  should 
not  make  an  opening  into  the  abdomen 
and  extract  the  cyst  itself.  Why  should 
not  a  Avoman  suffer  s]iaying,  Avithoiit 
danger,  as  Avell  as  other  animals  do?  The 
merely  making  an  opening  into  the  abdo- 
men is  not  highly  dangerous.    In  a  sound 


THE   IIISE   AND   PROGRESS   OF  OVARIOTOMY 


47 


constitution,  perhaps,  a  wound  merely  into 
the  abdomen  Avould  never  be  followed  by 
death  in  consequence  of  it.' 

Not  many  years  later  ( 1 798 )  ovariotomy 
found  an  enthusiastic  advocate  in  Cham- 
bon  ('Maladies  des  Femmes').  He  con- 
cludes a  speculative  chapter,  on  its 
applicability  to  other  diseases  besides 
ovarian  dropsy,  with  the  words,  '  I  am 
convinced  that  a  time  will  come  when  this 
operation  will  be  considered  practicable  in 
more  cases  than  1  have  enumerated,  and 
that  the  objections  against  its  performance 
will  cease.' 

John  Bell,  of  Edinburgh,  never  per- 
formed ovariotomy,  but  in  his  lectures 
dwelt  with  peculiar  force  and  pathos  upon 
the  hopeless  character  of  ovarian  tumours 
Avhen  left  alone,  and  upon  the  practicability 
of  removing  them  by  operation.  Ephraim 
McDowell,  a  Virginian,  and  a  student  in 
Edinburgh,  attended  Bell's  course  of  lec- 
tures in  1794.  It  is  said  of  him  by  his 
biographer,  Gross,  that  he  was  '  enrap- 
tured by  the  eloqi'.ence  of  his  teacher ; 
and  the  lessons  which  he  imbibed  were 
not  lost  upon  him  after  his  return  to  his 
native  country.  It  is  not  improbable 
that  the  young  Kentuckian,  Avhile  listen- 
ing to  the  teaching  of  the  ardent  and  en- 
thusiastic Scotchman,  determined  in  his 
own  mind  to  extirpate  the  ovaries  of  the 
first  case  that  should  present  itself  to  him 
after  his  return  to  his  native  country.  The 
subject  had  evidently  made  a  strong  im- 
pression upon  him,  and  had  frequently 
engaged  his  attention  and  reflection.  He 
had  thoroughly  studied  the  relations  of 
the  pelvic  viscera  in  their  healthy  and 
diseased  conditions,  and  felt  fully  per- 
suaded of  the  practicability  of  removing 
enlarged  ovaries  by  a  large  incision  through 
the  walls  of  the  abdomen.' 

McDowell  returned  to  Kentucky  in 
1795,  and  commenced  practice  at  once; 
but  it  was  not  until  14  years  afterwards 
that  he  was  consulted  (in  1809)  by 
a  patient  upon  whom  he  performed  ova- 
riotomy. 

No  one  can  dispute  the  validity  of  the 
direct  claim  of  McDowell  as  practically 
the  first  successful  ovariotomist.  At  the 
same  time  it  must  be  maintained,  that 
the  still  greater  merit  of  pointing  out 
the  absence  of  any  physiological  reasons 
against  the  operation,  the  possibility  of  its 
safe  performance  in  the  human  female,  and 
the  class  of  cases  in  which  it  ought  to  be 
admissible,  is  due  to  the   teaching  of  the 


'  Hunters  and  of  John  Bell.  But  in  this 
I  country,  such  is  the  sacredness  of  human 
i  life,  even  when  threatened  by  fatal 
disease ;  so  strong  is  the  consciousness 
that  the  introduction  of  innovations  like 
ovariotomy  insures  the  destruction  or 
shortening  of  a  certain  number  of  lives 
during  the  tentative  stage  of  the  practice, 
that  men  even  of  the  stamp  of  the  Hunters 
and  Bell  naturally  shrank  from  the  re- 
sponsibility, imposed  upon  them  by  their 
position  and  reputation,  of  adopting  and 
inaugurating  it  as  a  part  of  legitimate 
surgery.  And  it  must  be  remembered 
that,  at  that  time,  the  mortality  from  all 
operations  was  much  greater  than  it  is 
now ;  that  the  diseased  were  more  pas- 
sively quiescent  under  their  maladies  and 
less  tolerant  of  any  surgical  suggestions, 
just  as  we  ourselves  find  to  be  the  case 
among  the  population  of  an  outlying 
agricultural  district ;  and  that  they  were 
not  buoyed  up,  as  modern  women  are,, 
by  the  promises  of  painless  extirpations 
under  chloroform  or  methylene.  Every- 
one looked  upon  the  ending  of  the  dis- 
ease in  death  as  a  matter  of  course ;  and 
this  led  to  stolid  endurance  and  content- 
ment with  such  relief  as  medicine  and 
tapping  could  afford. 

But  McDowell  was  a  free  man,  in  a 
new  country,  clear  from  the  conventional 
trammels  of  old-world  practice.  He 
found  his  patients  in  the  most  favourable 
conditions  of  animal  life,  and  seems  to 
have  had  one  of  those  incomprehensible 
runs  of  luck  upon  which  a  man's  fate 
and  reputation  so  often  turn  if  he  has  the 
sagacity  and  energy  to  put  such  fortunate 
accidents  to  good  account ;  and  was 
happy,  as  those  usually  are  who  can 
afford  or  constrain  themselves  to  wait,  in 
finding  suitable  time,  place,  persons,  and 
opportunity  for  working  into  fact  the 
notions  of  his  tutor  Bell.  He  lost 
only  the  last  of  his  first  5  cases  of 
ovariotomy,  and  thus,  as  it  were,  es- 
tablished at  the  outset  what  until  recently 
was  regarded  as  a  satisfactory  standard 
of  mortality  for  so  serious  an  operation. 

The  details  of  his  first  operation,  as 
recorded  by  Gross,  are  interestinG;  enough 
lor  repetition  : 

'  It  Avas  performed  on  J\Irs.  Crawford, 
of  Kentucky,  in  December  1809.  The 
tumour  inclined  more  to  one  side  than  the 
other,  and  was  so  large  as  to  induce  her 
professional  attendant  to  believe  that  she 
was  in  the  last  stage  of  pregnancy.      She 


48 


OVAELIN   AND   ALLIED   TUMOURS 


was  affected  with  pains  similar  to  those 
of  labour,  from  Avhich  she  could  find  no 
relief.  The  wound  was  made  on  the  left 
side  oE  the  median  line,  some  distance 
from  the  outer  edge  of  the  straight  muscle, 
and  was  0  inches  in  length.  As  soon 
as  the  incision  was  completed,  the  intes- 
tines rushed  out  upon  the  table ;  and  so 
completely  was  the  abdomen  filled  by  the 
tumour  that  they  could  not  be  replaced 
during  the  operation,  Avhich  was  finished 
in  25  minutes.  In  consequence  of  its 
great  bulk,  Dr.  McDowell  Avas  obliged 
to  puncture  it  before  it  could  be 
removed.  He  then  threw  a  ligature 
round  the  Fallopian  tube,  near  the  uterus, 
and  cut  through  the  attachments  of  the 
morbid  growth.  The  sac  weighed  7^ 
pounds,  and  contained  15  pounds  of  a 
turbid,  gelatinous  -  looking  substance. 
The  edges  of  the  wound  being  brought 
together  by  the  interrupted  suture  and 
adhesive  strips,  the  woman  was  placed 
in  bed  and  put  upon  the  antiphlogis- 
tic  regimen.  "  In  5  days,"  says  Dr. 
McDowell,  "  I  visited  her,  and,  much 
■  to  my  astonishment,  found  [her  engaged 
in  making  up  her  bed.  I  gave  her 
particular  caution  for  the  future ;  and  in 
25  days  she  returned  home  in  good 
health,  which  she  continues  to  enjoy." 

'  It  will  not  be  uninteresting  here  to 
state  that  Mrs.  Crawford,  at  the  time  of 
the  operation  performed  upon  her  by  Dr. 
McDowell,  lived  in  Green  County,  Ken- 
tucky, from  whence  she  removed,  some 
time  afterwards,  to  a  settlement  on  the 
"Wabash  River,  in  Indiana,  where  she 
died,  March  30,  1841,  in  the  79th  year  of 
her  age.  There  was  no  return  of  her 
disease,  and  she  generally  enjoyed  excel- 
lent health  up  to  the  period  of  her  death. 
She  had  no  issue  after  the  operation. 
The  youngest  child,  Mr.  Thomas  H. 
Crawford,  who  has  kindly  communicated 
to  me  these  facts,  was  born  in  1803, 
nearly  six  years  before  the  operation.' 

McDowell,  as  a  surgeon,  was  exceed- 
ingly cautious,  calm,  and  firm  ■  paying 
great  attention  to  the  details  of  his  opera- 
tions and  treatment,  and  selecting  and 
drilling  his  assistants  with  much  care. 
Up  to  the  time  of  his  last  sickness,  he 
-was  one  of  the  most  active  men  in 
Kentucky,  and  he  died,  literally,  in  har- 
ness. 

McDowell  was  buried  in  the  cemetery 
near  the  scene  of  his  life-work,  and  in 
1879    it  was   deemed  a  fitting   thing    to 


perpetuate  the  world-wide  association  of 
his  name  with  ovariotomy  by  a  granite 
obelisk  and  some  characteristic  inscrip- 
tions. 

McDowell's  case  has  long  been  con- 
sidered the  first  ovariotomy  on  record  ; 
for  the  operation  of  L'Aumonier  of  Rouen, 
in  177G — which  Atlee,  in  his  table, 
enumerated  as  the  first  operation  of  ova- 
riotomy— was  in  a  case  of  pelvic  abscess, 
which  he  opened  by  an  incision  through 
the  wall  of  the  abdomen  above  Poupart's 
ligament,  six  or  seven  weeks  after  parturi- 
tion. He  seems  also  to  have  separated 
the  fimbria3  of  the  Fallopian  tube  from  the 
sac  of  the  abscess,  and  to  have  removed 
the  ovary  without  any  necessity,  and 
without  any  idea  of  ovariotomy. 

Another  case,  included  in  some  of  the 
tables  of  ovariotomy  by  Professor  Dzondi, 
is  one  in  which  a  pelvic  tumour  was  cured 
by  drawing  out  a  cyst  through  an  incision 
in  the  abdominal  wall  of  a  boi/  12  years 
old. 

Atlee,  however  (in  the  '  American 
Journal  of  Medical  Sciences,'  1849), 
brought  into  notice  an  operation  which 
claims  the  priority  to  that  of  McDowell 
by  more  than  a  century.  It  is  the  case  of 
Dr.  Robert  Hoiistoun,  wRich  may  be 
found  in  the  '  Philosophical  Transactions  ' 
(London,  1734),  under  the  head,  '  A 
dropsy  of  the  left  ovary  of  a  woman, 
aged  53  years,  cured  by  a  large  incision 
made  in  the  side  of  the  abdomen.'  From 
this  case  it  will  appear  that  ovariotomy 
originated  with  British  surgery,  on  British 
ground,  inasmuch  as  though  the  operation 
was  not  one  of  complete  excision  of  the 
tumour,  it  was  planned  with  that  inten- 
tion. 

Dr.  Robert  Hoiistoun  operated,  in 
August  1701,  near  Glasgow,  on  a  Mrs, 
Margaret  Miller,  who  since  her  last 
confinement,  13  years  before,  when 
23  years  of  age,  suffered  from  ovarian 
dropsy.  She  was  much  wasted,  had 
great  diflficulty  in  breathing,  want  of 
appetite  and  sleep,  and  bed-sores  from 
long  confinement.  The  tumour  had  grown 
to  a  monstrous  bulk.  This  case  is  in  many 
respects  a  very  curious  one,  and  the  opera- 
tor's own  words  are  worthy  of  record. 
He  says:  'After  having  obtained  the 
patient's  consent  that,  in  order  effectually 
to  relieve  her,  I  must  lay  open  a  great 
part  of  her  belly,  and  remove  the  cause 
of  all  that  swelling  .  .  .  I  prepared  Avith- 
out   loss  of  time  what  the  place  would 


THE  RISE   A^D   PROGRESS  OF  OVARIOTOMY 


49 


allow,  and  with  an  imposthume  lancet  laid 
open  about  an  inch  ;  but  finding  nothing 
issue,  I  enlarged  it  2  inches ;  but  even 
then  nothing  came  forward  but  a  little 
thin  yellowish  serum,  so  I  ventured  to  lay 
open  2  inches  more.  I  was  not  a  little 
startled,  after  so  large  an  aperture,  to  find 
it  stopped  only  by  a  glutinous  substance. 
All  my  difficulty  was  to  remove  it.  I 
tried  my  probe — I  endeavoured  with  my 
fingers,  but  all  was  in  vain ;  it  was  so 
slippery  that  it  eluded  every  touch  and 
the  strongest  hold  that  I  could  take.  I 
wanted  in  this  place  almost  everything 
necessary,  but  bethought  myself  of  a  very 
odd  instrument,  but  as  good  as  the  best, 
because  it  answered  the  end  proposed.  I 
took  a  strong  fir-splinter,  Avrapped  some 
loose  lint  about  the  end  of  it,  and  thrust 
it  into  the  wound ;  and  by  turning  and 
winding  it,  I  drew  out  about  2  yards  in 
length  of  a  substance  thicker  than  any 
jelly,  or  rather  like  glue  that  is  fresh 
made  and  hung  out  to  dry ;  the  breadth 
of  it  was  above  10  inches.  This  was 
followed  by  9  full  quarts  of  such  matter 
as  I  have  met  with  in  steatomatous 
and  atheromatous  tumours,  with  several 
hydatids  of  various  sizes  containing  a 
yellow  serum,  the  least  of  them  bigger 
than  an  orange,  with  several  large  pieces 
of  membrane,  which  seemed  to  be  parts 
of  the  distended  OA^ary.  Then  I  squeezed 
out  all  I  could,  and  stitched  up  the  wound 
in  3  places,  almost  equidistant.  The 
lower  part  of  the  wound  was  kept  open  by 
a  small  tent.  Some  serosity  discharged 
from  it  for  4  or  5  days.  The  Avound 
Avas  covered  in  its  whole  length  Avith  a 
pledget  spread  Avith  some  home-made 
balsam,  over  that  several  compresses 
dipped  in  Avarm  brandy,  then  several 
tOAvels ;  all  these  dressings  Avere  fastened 
by  swathing  her  round  the  body.  An 
anodyne  Avas  given  several  times  a  day. 
The  next  morning  the  patient  Avas  found 
much  refreshed  by  a  good  night's  rest, 
the  first  she  enjoyed  for  3  months  past. 
After  3  Aveeks  she  was  able  to  sit  out- 
doors, wrapped  up  in  blankets,  superin- 
tendingherfarm-labourers.  She  recovered, 
and  lived  in  perfect  health  firom  that  time 
till  October  1717,  Avhen  she  died  after  10 
days'  illness.' 

Although  this  isolated  case  undoubt- 
edly strengthens  the  claim  of  British 
surgery  to  the  honour  of  originally  at- 
tempting ovariotomy,  it  will  hardly  de- 
prive McDowell  of  his  undeniable  merit 


of  having  been  the  firit  Avho,  guided 
by  scientific  principles,  enriched  modern 
surgery  with  the  operation  Avhich  he  per- 
formed 13  times  between  1809  and 
his  death  in  1830.  The  precise  number 
of  deaths  cannot  be  ascertained ;  but 
of  8  cures  there  can  be  no  doubt. 
McDoAvell's  successes  Avere  followed  up 
by  other  American  surgeons.  In  1822, 
Mr.  N.  Smith,  of  Connecticut,  remoA^ed  a 
cyst  containing  G  pints  of  fluid,  through 
an  incision  5  inches  long.  lie  broke 
down  extensive  adhesions  betAveen  the 
tumour  and  the  abdominal  Avail  and  the 
omentum.  The  Avound  Avas  united  Ijy 
means  of  adhesive  plaster  and  roller.  No 
unfavourable  symptom  occurred  until 
the  separation  of  the  ligature,  Avhen 
an  abscess  formed,  Avhich  had  to  be 
opened.  The  patient,  23  years  of  age, 
was  able  to  Avalk  after  3  Aveeks,  and 
speedily  recovered.  In  another  case 
Smith  Avas  unable  to  complete  the  opera- 
tion on  account  of  extensive  adhesions.. 
He  emptied  the  cyst,  and  the  patient 
recovered.     But  the  cyst  filled  again. 

In  1823,  G.  Smith  removed  an  OA^arian 
tumour  from  a  negress,  through  an  in- 
cision extending  from  the  umbilicus  to 
the  OS  pubis,  after  having  emptied  the 
contents  of  the  cyst.  The  pedicle  Avas 
secured  by  a  ligature.  The  patient  re- 
covered Avithin  25  days. 

Lizars,  of  Edinburgh,  Avas  the  first 
to  attempt  ovariotomy  in  this  country. 
He  performed  2  operations  in  1825,  of 
Avhich  the  first  was  successful,  the  second 
fatal  in  56  hours.  He  opened  the  abdo- 
men on  2  other  occasions,  but  only  to 
prove  errors  of  diagnosis.  Both  patients 
recovered. 

The  first  attempt  to  perform  ovario- 
tomy in  London  Avas  made  in  1827,  by 
Dr.  Granville,  who  operated  in  2  cases. 
In  one  the  operation  was  abandoned  on 
account  of  the  extent  of  the  adhesions ; 
the  Avoman  recovered.  In  the  other  case 
a  fibrous  tumour  of  the  uterus,  Aveighing 

8  pounds,  was  removed ;  but  the  patient 
died  on  the  third  day. 

The  ill-success  of  Lizars  and  Gran- 
ville, Avho  both  operated  by  the  long 
incision,  brought  discredit  upon  the 
operation ;   and  it    Avas  not    until    183G, 

9  years  after  Granville's  failures,  that 
a  provincial  surgeon,  Jeafireson,  of  Fram- 
lingham,  acted  upon  the  suggestion  of 
William  Hunter,and  performed  ovariotomy 
by  the  small  incision  for  the  first  time 

E 


50 


OVARIAN  AND   ALLIED  TUMOUES 


in  Great  Britain.  A  bilocular  cyst  was 
removed  through  an  opening  only  an 
inch  and  a  half  long.  The  patient 
afterwards  gave  birth  to  1  boy  and  3 
girls,  and  was  alive  in  1859,  5G  years  of 
age. 

In  the  same  year  (LS3G),  another 
provincial  surgeon,  Mr.  King,  of  Sax- 
mundham,  successfully  removed  an  ova- 
rian cyst  through  an  incision  3  inches 
long ;  and  Mr.  West,  of  Tonbridge,  also 
had  a  successi'ul  case,  the  incision  being 
only  2  inches  long.  In  1838,  Mr. 
Crisp,  of  Harleston,  removed  a  multi- 
locular  cyst  through  an  incision  only  1 
inch  long.  The  patient  lived  15  years 
after  the  operation,  and  enjoyed  good 
health. 

In  1839,  Mr.  West,  of  Tonbridge, 
had  a  second  successful  case  ;  a  single 
cyst,  which  contained  22  pints  of  fluid, 
having  been  removed  by  the  short  in- 
cision. Mr.  West  also  had  an  imsuccess- 
ful  case  of  completed  ovariotomy,  and 
one  in  which  the  adhesions  prevented  the 
completion  of  the  operation.  In  the  same 
year  the  first  attempt  to  perform  ovario- 
tomy in  a  London  hospital,  of  which  I 
have  been  able  to  find  any  record,  was 
made  at  Guy's,  by  Mr.  Morgan.  A  small 
incision  Avas  made,  adhesions  were  found, 
the  tumour  was  not  removed,  and  the 
patient  died  in  24  hoiu-s. 

In  1840,  Benjamin  Phillips  ope- 
rated at  the  Marylehone  Infirmary,  and 
completed  the  operation  for  the  first  time 
in  London ;  but  the  result  was  unsuc- 
cessful. 

In  1842,  Dr.  Clay,  of  Manchester, 
commenced  his  series  of  operations,  per- 
forming ovariotomy  4  times,  and  in  3 
out  of  the  4  with  success.  In  1843, 
lie  also  operated  4  times,  twice  success- 
luUy.  In  1843,  Aston  Key  removed 
both  ovaries  from  a  patient  in  Guy's 
Hospital.  His  incision  extended  from 
the  ensiform  cartilage  to  the  pubes, 
and  death  followed  on  the  4th  day. 
Later  in  the  same  year,  Bransby  Cooper 
operated  in  the  same  hospital  by  the  long 
incision,  and  removed  a  large  midtilocular 
cyst,  but  the  patient  died  on  the  7th 
day. 

So  that  42  )-cars  ago,  although 
ovariotomy  had  been  performed  with 
success  in  1  case  in  Scotland,  and  in  at 
least  10  cases  by  surgeons  in  our  own 
provinces,  it  had  never  been  peribrmed 
buccessfully  in  London.     It  was  the  good 


fortune  of  Mr,  Walne  to  perform  the  first 
successful  operation  in  London,  in  No- 
vember 1842;  and  he  had  2  other 
successful  ca.ses  in  May  and  September 
1843.  In  that  year,  and  in  1844,  Dr. 
Frederic  Bird  had  3,  and  Mr.  Lane 
2  successful  cases.  Mr.  Lane's  first 
patient  was  still  alive  in  18G7,  and  had 
7  children.  In  1843  and  1845,  Mr. 
Southam,  of  Salford,  and  in  1845,  Mr. 
Dickson,  of  Shrewsbury,  published  suc- 
cessful cases.  In  1846,  Mr.  H.  E.  Burd 
operated,  his  patient  recovered,  and  had 
a  child  2  years  after  the  operation. 

In  the  same  year  Mr.  Solly  took  ad- 
vantage of  an  un.successful  case  which 
occurred  in  his  practice  in  St.  Thomas's 
Plospital  to  point  out  that  retraction  of 
the  pedicle  behind  the  ligature  is  very 
likely  to  occur  and  to  lead  to  fatal 
haBmorrhage,  unless  prevented  by  groat 
care.  His  published  lecture  on  this  case 
contains  a  masterly  review  of  the  argu- 
ments for  and  against  the  operation,  which 
must  have  had  considerable  eff'ect  upon 
the  mind  of  the  profession  at  the  time. 

The  year  184G  is  also  noteworthy 
in  the  history  of  ovariotomy.  In  the 
month  of  September,  Ctesar  Hawkins  per- 
formed the  operation  for  the  first  time 
successfully  in  any  London  hospital. 
Even  now,  after  this  long  interval,  with 
all  our  accumulated  experience,  it  is  not 
only  interesting  but  useful  to  look  back 
upon  this  initial  glimpse  of  success  and 
reopen  the  pages  of  the  clinical  lecture 
Avhich  was  its  record  and  commentary. 
The  cautioiis  delibei-ation  Avith  which  the 
operation  was  decided  upon,  the  attention 
to  all  the  maxims  of  scientific  surgery 
which  went  with  every  step  of  the  work, 
the  skill  and  •  precaution  with  wdiich  it 
was  executed,  and  the  judicious  after- 
treatment  of  the  patient,  all  offered  an 
example  for  imitation  as  much  as  the 
lecture  furnished  a  lesson  for  study  in  the 
exactitude  of  its  details,  the  lucidity  of 
its  expositions,  and  the  judiciousness  of 
its  advice.  It  was  a  simple  case  admir- 
ably recorded.  Mv.  Hawkins  did  not 
repeat  the  operation,  and  his  example 
was  not  much  followed  by  othei's  for 
several  years.  Dr.  F.  Bird  and  IVIr.  Lane 
were  the  only  operators  in  London, 
exceiDt  Dr.  J^-otheroe  Smith,  Avho  had 
succes.sful  cases.  Dr.  Clay  continued  his 
operations  at  jNIanchester,  and  successful 
cases  were  recorded  by  Dr.  Elkington, 
of  Birmingham,  and  by  Mr.  Crouch,  in 


THE   RISE  AND  PROGRESS   OF   OVARIOTOMY 


51 


]84:9,  and  by  Mr.  Cornish,  of  Tuunton, 
and  Mr.  Day,  of  Walsall,  in  1850. 

In  Ls5r3,  Mr.  Duffin  inaugurated  a 
new  era  in  ovariotomy,  by  raising  the 
ciUGstion  of  the  danger  of  leaving  the  tied 
end  of  the  pedicle  within  the  peritoneal 
cavity,  and  by  insisting  upon  the  in:iport- 
ance  of  keeping  the  strangulated  stump 
outside.  He  was  brought  to  the  resolution 
of  adopting  this  extra-peritoneal  treat- 
ment of  the  pedicle  not  by  any  accidental 
necessity,  but  by  '  reflecting  on  the 
fatal  termination  caused,  as  it  appeared  to 
him,  on  separation  of  the  slough,  by  putre- 
factive decomposition  within  the  j^eri- 
toneal  cavity.'  It  suggested  itself  to  him 
that  '  this  latter  consequence,  as  Avell  as 
the  irritation  caused  by  the  ligature  in 
the  abdomen,  might  be  obviated  by  keep- 
ing the  tied  portion  completely  out  of 
the  cavity.'  He  determined,  therefore, 
to  fix  the  end  of  the  pedicle  outside  the 
edges  of  the  wound ;  but  in  the  only  case 
lie  reported,  he  was  obliged,  to  content 
himself  by  stitching  the  cut  extremity 
iind.  ligature  in  the  wound.  It  answered 
■completely.  The  only  objection  was  the 
dragging  of  the  abdominal  wall  towards 
the  spine ;  biit  no  adhesions  formed,  and 
the  abdomen  soon  returned  to  its  natural 
Ibrm. 

Whatever  may  be  cur  opinions  and. 
practice  at  the  present  time,  and  Avhatever 
views  we  may  hold  upon  the  question 
whether  this  extra-peritoneal  treatment 
of  the  pedicle  has  advanced  or  retarded 
the  success  of  the  operation,  Mr.  DufEn's 
arguments  led  to  great  changes  and  re- 
sults— to  the  use  of  the  clamp  and  to  all 
the  modifications  of  treatment  attendant 
upon  it,  and  ultimately  to  researches  as  to 
the  physiological  and  pathological  phe- 
nomena of  ligatured  stumps  within  the 
peritoneal  cavity,  and  to  the  study  of  the 
important  subject  of  drainage  by  Kceberle 
and  others. 

Some  German  writers  think  that  the 
credit  here  given  to  Duffin  should  be 
awarded  to  Stilling;  because  in  1841  he 
published  a  case  in  which  he  sewed  the 
pedicle  with  a  part  of  the  cyst  between 
the  lips  of  the  wound  in  the  abdominal 
wall,  after  he  had  stopped  the  bleeding 
by  torsion,  ligature,  and  the  cautery. 
But  this  can  hardly  be  called  a  truly 
extra-peritoneal  treatment.  It  is  more 
like  Avhat  Langenbeck  in  18.51  described 
as  ^Einnahen,'  and  Storer  in  18G7  as 
'pocketing   the   pedicle.'      It   was   after 


Duffin  that  Stilling  adopted  a  complete 
extra-peritoneal  method  by  transfixing 
the  tied  pedicle  with  a  needle  outside  the 
closed  wound.  Martin  afterwards  thus 
far  varied  Stilling's  method,  sewing  only 
the  peritoneal  coat  of  the  pedicle,  instead 
of  the  base  of  the  tumour,  to  the  abdomi- 
nal wall.  This  question  was  first  dis- 
cussed in  any  work  of  authority  by 
Erichsen,  in  the  first  edition  of  his 
'  Science  and  Art  of  Surgery,'  published 
in  1853.  He  haji  then  done  the  opera- 
tion twice — one  very  successful  case  re- 
lated in  the  woi-k,  and  one  where  the 
operation  was  not  completed.  These 
operations  Avere  performed  in  1852. 

I  began  work  in  London  in  1853,  and 
in  the  following  year  joined  what  is  now 
called  the  Samaritan  Hospital.  At  this 
time  I  did  nothing  but  out-patient  work, 
and  in  January  1855  went  off  to  the 
Crimea.  But  in  the  April  before,  I  had 
made  my  first  acquaintance  with  ovario- 
tomy. Baker  Brown  invited  me  to  see 
him  operate,  and  I  went  with  Mr.  Nunn 
and  assisted  him.  It  was  his  8th  case, 
a  dermoid  cyst  with  adhesions,  which 
made  the  proceedings  long  and  trouble- 
some. Nine  days  after,  the  patient  died 
of  what  we  can  now  recognise  as 
septicajmia.  This  so  influenced  Brown 
that  he  only  did  one  more  case,  and 
that  unsuccessfully,  during  the  next  four 
years  and  a  half,  saying  that  '  it  was 
of  no  use,  peritonitis  would  always  beat 
one.'  I  was  not  favourably  impressed, 
but  had  learnt  how  some  of  the  great  dif- 
ficulties might  be  overcome  so  far  as  the 
operation  itself  Avas  concerned.  Away 
from  England,  in  all  the  excitement  of 
Avar-surgery,  of  course  the  subject  Avas  at 
rest.  But  after  my  return  in  1856  I  re- 
sumed out-patient  Avork  in  Orchard  Street. 
We  did  not  often  see  cases  of  OA^arian 
disease  at  that  time,  but  they  did  appear 
occasionally.  As  I  have  said,  Bi-own  had 
given  up  the  operation  ;  very  few  others 
Avere  attempting  it,  and  most  men  Avere 
lapsing  into  the  old  state  of  indifference, 
if  they  Avere  not  loudly  protesting  against 
it.  During  the  autumn  of  1857  a  young 
Avoman  was  under  treatment  for  Avhat 
appeared  to  be  an  ovarian  tumour  on  the 
left  side.  Opinions  Avere  confidently  ex- 
pressed that  this  could  not  be  an  OA^arian 
tumour,  because  intestines  could  be 
felt  in  front  of  it.  But  I  determined 
to  see  Avhat  it  Avas,  and  in  December 
1857,  27  years  ago,  I  prepared  for   my 

E  2 


O-i 


OVARIAN  AND   ALLIED  TUMOURS 


first  ovariotomj'.  Reflecting  upon  all 
the  ways  and  forms  of  using  the  liga- 
ture, I  had  resolved  to  use  the  ecraseur 
for  the  division  of  the  pedicle,  as  was  done, 
some  months  after  the  publication  of  my 
suggestion,  by  Dr.  John  L.  Atlee.  We 
cleared  out  the  waiting-room,  got  a  bed 
there,  and  secured  a  nurse.  As  soon  as  I 
opened  the  peritoneum,  and  it  was  proved 
beyond  all  doubt  that  the  tumour  was 
behind  the  intestines,  I  was  induced  very 
unwillingly  to  close  the  Avound  and  do 
nothing  more.  The  patient  recovered 
without  any  bad  symptom,  but  died  4 
months  afterwards  in  St.  Bartholomew's 
Hospital,  when  it  was  found  that  there  was 
a  tumour  of  the  left  ovary,  which  might 
have  been  removed  quite  easily.  This 
Avas  not  encouraging  for  a  beginner,  but 
it  attracted  the  notice  of  Mr.  Bullen,  of 
the  Lambeth  Workhouse,  and  he  offered 
me  a  patient  then  in  his  in6rmary  who 
had  been  tapped  3  times  in  Guy's 
Hospital  and  4  times  in  Lambeth  Work- 
liouse,  and  had  had  iodine  injected. 
As  she  was  willing  to  face  any  risk,  I  did 
ovariotomy  for  her  in  February  1858.  The 
pedicle  was  treated  by  whipcord  ligature, 
the  ends  hanging  out  at  the  lower  angle  of 
the  wound  after  the  fashion  of  Clay,  Bird, 
Brown,  and  the  earlier  ovariotomists.  At 
that  time  we  had  a  house-surgeon,  Mr. 
Cooke,  and  greatly  owing  to  his  constant 
care  the  poor  girl  recovered.  She  became 
a  nurse  in  the  hospital,  went  into  service, 
then  emigrated,  and  I  heard  of  her  in 
18C8,  married  to  the  German  overlooker 
of  a  large  estate  in  Queensland,  whose 
salary  was  240/.  a  year.  Had  ovariotomy 
not  been  performed,  slie  must  have  died 
in  1858  a  pauper  in  a  workhouse. 

Between  this  1st  case,  in  February 
1858,  and  the  2nd  in  August  of  the 
same  year,  we  had  removed  to  Scvmour 
Street,  where  the  hospital  now  is,  and  tlie 
2nl  operation  was /done  in  one  of  the 
rooms  in  Avhich  1  afterwards  completed 
the  long  series  of  408  hospital  cases. 

The  3rd  case  was  in  the  following 
November,  and  haj^pily  all  the  three 
women  recovered.  Had  tliey  died,  such 
was  ilie  state  of  professional  opinion  at 
tliat  time,  the  progress  of  ovariotomy 
might  have  been  sadly  retarded. 

I  lost  my  4th  ovariotomy  without 
l)eing  able  to  account  for  the  death.  It 
was  the  fir.st  post-mortem  I  had  occasion 
to  make.  Dr.  Aitken  assisted  me,  and  he 
found  that  the  hare-lip  pins  which  I  then 


used  as  sutitres  were  bare  on  the  inner 
aspect  of  the  abdominal  wall,  the  cut  edges 
of  the  peritoneum  were  retracted,  and  a 
portion  of  intestine  was  in  contact  witb 
the  wound,  the  impress  of  which  was 
obvious  on  the  surface  of  the  gut.  Some 
coagula  of  blood  and  an  abundant  con- 
sistent lymph  exudation  tipon  the  peri- 
toneal surface  of  the  intestine  corresponded 
with  the  edges  of  the  incision  and  the 
sui-face  of  the  wound.  Recent  lymphs 
glued  the  opposing  surfaces  of  the  intes- 
tines to  each  other.  I  saw  at  once  how* 
much  better  it  might  have  been  if  t he- 
peritoneal  edges  had  been  brought  accu- 
rately together,  and  thought  of  doing  this 
in  my  next  case.  But  I  found  instruc- 
tions in  text-books  and  treatises  carefully 
to  avoid  the  peritoneum.  These  doctrines 
were  at  variance  Avith  the  facts  before  my 
eyes.  Physiological  principles  had  been 
overlooked.  I  did  not  question  them,  but 
now  that  an  important  practical  question 
Avas  raised  which  bore  distinctly  upon  the 
failure  of  my  operation,  I  determined  to 
put  them  to  the  test.  I  made  experiments 
upon  dogs,  rabbits,  and  guinea-pigs,  for 
Avhich  I  have  been  vilified,  but  for  Avhicli 
I  do  not  reproach  myself.  The  prepara- 
tions Avhich  I  procured  fi-om  these  animals 
are  still  preserved  in  the  Mu.seum  of 
the  Royal  College  of  Surgeons.  They 
corroborated  Avhat  Avas  knoAvn  Jjefore^ 
that  abdominal  Avouuds  Avell  auj^J§ted 
unite  readily.  This  Avas  not  Avhat  "t*- 
Avanted.  They  proved  more,  and  Avere 
the  visible,  standing  evidence  Avhich  I 
did  Avant,  that  though  the  other  tissues 
might  be  brought  together,  if  the  cut 
edges  of  the  peritoneum  Avere  left  free, 
they  retracted,-  direct  union  did  not  take 
place,  and  secondary  evil  consequences 
resulted.  In  the  specimens  Avhere  the 
divided  edges  or  rather  surfaces  of  jieri- 
toneum  have  been  pressed  together,  the 
smooth  serous  inner  coat  of  the  abdominal 
wall  is  perfectly  restored.  The  stitches 
cannot  be  seen  on  the  inside,  though 
plainly  visible  on  the  skin,  and  there  i.s- 
no  adhesion  of  intestine  or  omentum. 
But  in  other  specimens,  Avhere  the  peri- 
toneal edges  Avere  purposely  excluded 
from  the  sutures,  and  the  animal  Avas  not 
killed  for  a  day  or  two,  intestine  or 
omentum  adheres  to  the  inner  surface  of 
the  abdominal  Avail,  thus  completing  the 
peritoneal  sac  at  the  great  risk  of  intestinal 
obstruction,  to  say  nothing  of  a  Avant  of 
firm  union  and  subsequent  ventral  hernia. 


THE   KISE  AND   PllOGRESS   OF  OVARIOTOMY 


Without  tills  convincing  demonstration  in 
my  hands,  I  might  have  gone  on  for  years 
bowing  to  precepts  and  oblivious  of  prin- 
ciples, sometimes  taking  up  the  peritoneum 
and  sometimes  leaving  it  loose,  with  per- 
plexity to  myself  and  danger  to  my 
pntients.  But  my  lesson  was  learnt,  and 
I  cannot  too  strongly  inculcate  it  upon 
'Others.  When  skin  or  mucous  membrane 
is  divided,  the  edges  must  be  brought 
together  to  secure  direct  union.  If  they 
be  inverted,  union  is  prevented.  The 
<jxact  opposite  holds  good  with  serous 
membranes.  The  edges  should  be  in- 
verted, and  two  surfaces  of  membrane 
pressed  together,  so  that  the  sutures  are 
not  seen.  The  effused  lymph  then  makes 
so  smooth  a  surface  that  even  the  line  of 
UQion  cannot  be  seen.  This  appeared  to 
be  good  and  promising  work  for  1859, 
and  1  felt  that  I  was  announcing  what  was 
indisputably  true ;  but,  as  often  happens 
at  first,  the  fruits  did  not  equal  my  ex- 
pectations, for  I  had  the  misfortune  to 
lose  5  cases  out  of  the  11  which  I  did 
during  the  year,  3  in  hospital  and  2  in 
private  practice. 

The  translation  in  1860  of  Kiwisch's 
Chapters  on  Diseases  of  the  Ovaries  by 
■Clay,  of  Birmingham,  with  the  very  valu- 
able tables  appended  to  the  work,  must  be 
regarded  as  greatly  assisting  in  the  pro- 
gress of  ovariotomy  in  this  country. 
Baker  Brown's  success  with  the  cautery, 
Tyler  Smith's  revival  of  the  practice 
■of  returning  the  pedicle  Avith  the  ligature 
around  it,  and  the  numerous  published 
cases  of  Hutchinson,  Bryant,  Murray,  and 
•other  surgeons,  all  had  their  share  in  the 
general  result. 

Within  the  next  5  years  I  completed 
114  operations,  and  in  1864  published 
my  first  book,  which  Avas  a  record  of 
•every  case,  Avith  such  commentaries  as 
the  experience  acquired  and  tlie  dis- 
cussions of  the  day  seemed  to  make  it 
a  duty  to  lay  before  the  public.  On 
taking  up  this  subject  as  a  matter  of 
study  and  trial,  just  at  the  crisis  Avhen 
obloquy  was  the  thickest  and  opposition 
the  strongest,  I  felt  that  nothing  but  the 
most  open  frankness  would  carry  con- 
viction of  success,  or  in  case  of  failure 
justify  the  operation.  I  was  not  uncon- 
scious of  the  fact  that,  however  much  I 
might  devote  myself  to  it  as  a  professional 
obligation,  and  as  a  response  to  a  despair- 
ing cry  from  a  crowd  of  hopeless  women, 
it  was  looked  upon  as  a  surgical  enter- 


prise wliich  had  baffled  otiiers,  and  from 
which  many  had  withdrawn  discom- 
fited. I  therefore  pledged  myself  to  make 
known  tlirough  the  press  all  that  I  did 
and  all  that  befell  me,  and  my  book  Avas 
the  formal  redemption  of  that  pledge, 
gathering  up  as  it  did  all  the  isolated 
details  of  my  practice,  and  the  scattered 
remarks  published  from  time  to  time  in 
the  journals.  During  this  period  of  5 
years,  and  in  treating,  as  it  then  seemed, 
the  long  series  of  cases,  nearly  all  the 
questions  of  practical  importance  and 
speculative  interest  came  up  for  considera- 
tion, and  Avere  rendered  intensely  pertinent 
from  the  urgency  of  their  actual  applica- 
tion. Up  to  the  time  of  my  beginning  to 
operate,  there  Avas  but  little  concord  among 
my  predecessors  as  to  the  mode  of  doing 
the  operation,  and  scarcely  any  reference 
to  scientific  principles  in  choosing  this  or 
that  course.  Ignorance  of  anajsthetics 
had  long  kept  so  formidable  a  proceeding 
out  of  the  hands  of  all  but  the  most  daring 
of  surgeons,  and  out  of  the  thoughts  of  any 
but  the  most  desperate  of  patients.  But 
noAV,  in  the  calmness  of  ether  and  chloro- 
form, and  Avith  the  possibilities  of  the 
older  surgeons  reduced  to  demonstrated 
facts,  attention  began  to  be  concentrated 
upon  details  and  accidents.  Problems  of 
diagnosis,  the  means,  as  Hunter  expressed 
it,  '  of  knoAving  beforehand  that  the  cir- 
cumstances Avould  admit  of  such  treatment,' 
the  relative  safety  of  long  or  short  inci- 
sions, the  mode  of  dealing  Avith  the  pedicle, 
the  tolerance  of  the  peritoneum,  the  best 
Avay  of  closing  the  Avound,  the  real 
value  of  opium  in  the  after  treatment, 
the  temperature  and  regimen  to  be  ob- 
served, the  distinction  between  peritonitis 
and  reaction,  the  nature  and  cause  of 
septicaemia,  and  the  after  consequences  of 
the  operation  ;  all  these  and  other  subjects, 
affecting,  by  the  Avay  in  Avhich  they  might 
be  decided,  the  results  of  ovariotomy,  were 
presenting  themselves  to  the  practitioner 
and  demanding  his  judgment.  It  Avould 
have  been  absurd  on  my  part  to  pretend 
that  I  Avas  arriving  at  absolute  truth,  or 
to  enunciate  anything  like  un(]uestionable 
maxims.  But  as  facts  accumulated,  as  I 
became  familiarised  with  difficulties,  aAvare 
of  sources  of  danger,  and  learnt,  either  by 
trial  or  from  others,  better  modes  of  pro- 
cedure, I  formed  opinions,  acted  upon 
them,  and  offered  them  for  criticism. 
1  have  often  regretted  that  I  failed  to 
become     sooner     acquainted     with     the 


o4 


OVARIAN   AND   ALLIED   TUMOURS 


clinical  lecture  of  Ca-sar  Hawkins,  whicli 
would  have  cleared  my  "way  through 
some  difficulties,  and  dissipated  some 
shadows  which  perplexed  me.  But  on 
reference  to  my  volume  of  18G4,  it  will 
he  seen  that  I  soon  came  to  the  con- 
clusion that  it  was  a  matter  of  no  in- 
superable difficulty  to  decide  u-pon  the 
practicability  of  the  operation,  and  that 
an  exploratory  incision  was  a  justifiable, 
sometimes  useful,  and  almost  always  a 
harmless  proceeding.  With  regard  to  the 
incision,  it  wanted  no  magician  to  demon- 
strate that  length  was  a  i-elative  quantity, 
that  it  would  bs  as  stupid  to  make  a  cut 
ten  inches  long  for  the  extraction  of  a 
tumour  the  size  of  a  cricket-ball,  as  it 
would  be  madness  to  try  to  drag  a  semi- 
solid multilocular  mass  through  Jeaffre- 
son's  minimum  opening.  I  therefore 
acted  upon  the  rule  of  giving  myself  room 
according  to  the  size  and  solidity  of  the 
tumour,  keeping  as  near  the  safe  medium 
length  as  possible  ;  and  when  an  opening 
was  too  small  for  a  large  multilocular 
tumour  to  pass  through  as  it  was,  I 
soon  began  to  break  down  the  interior 
of  the  tumour  with  my  hand,  thiis  render- 
ing the  operation  easier,  and  insuring  its 
completion  in  many  cases  which  Avould 
formerly  have  been  abandoned. 

As  to  the  pedicle  there  was  more 
hesitation.  No  one  knew  exactly  what 
should  be  done.  I  tied  it  and  left  the  liga- 
tures hanging  out  through  the  wound,  as 
others  had  advised.  I  tied  it  and  let  it 
drop  into  the  abdomen.  I  fixed  it  in  the 
wound  with  a  ligature  and  pins.  I  secured 
it  outside  the  wound  with  a  clamp.  I 
cauterised  it  and  left  it.  I  combined 
the  cautery  and  ligature.  I  made  a 
solitary  essay  with  the  ecraseur,  and  I 
conjoined  and  modified  most  of  these 
procedures.  Every  plan  had  its  special 
difficulties  and  dangers,  and  one  pecu- 
liarity of  all  this  tentative  work  was,  that 
it  brought  the  disadvantages  more  con- 
spicuously into  view  than  the  advantages. 
It  is  impossible  now,  with  the  results  of 
the  experience  of  more  than  five-and- 
twenty  years  tabulated  and  criticised, 
and  practice  running  in  two  or  three 
ecjually  approved  grooves,  for  anyone  to 
form  an  idea  of  the  perplexity  which 
formerly  made  every  movement  in  advance 
dubious.  Circumstances  sometimes  took 
away  the  groxmd  of  option,  as  when  the 
pedicle  was  too  short  to  be  l)ronght  out 
of  the   wound   and   clamped.     But   upon 


the  whole,  in  accordance  with  M'hat  was 
the  then  belief,  that  a  tied  pedicle,  whether 
inclosed    or    left    to    drain     through    an 
aperture,  must   undergo    the   process    of 
gangrene    and  sloughing,    the    notion    of 
extra-peritoneal  treatment  was   theoreti- 
cally right;    and  it  was    this   conviction, 
together  with  some  practical  objections  to 
the  ligature  and  cautery,  that  led  me  to 
give    the    preference   to   fixation    exter- 
nally by  the  clamp.     The  greater  part  of 
the    pedicles    during  this    section  of  my 
operative  work  were  treated  in  this  way. 
There  were  no  statistics  to  judge  by,  but 
I  seemed  to  be  doing  better  with  it ;  and 
later  on,  when  numbers  augmented,  they 
proved  that  the  mortality  in  clamp  cases 
Avas  less  than  the  general  average,  and 
vastly   lower    than    that    given    by   the 
ligature.     It  is  true  that  the  cases  I  did 
with    the    cautery   turned  out  well,   but 
they  were  few  in  number;  and  though 
Baker    Brown    was    concurrently    doing 
better  still  with   it,  I  was  not  assured  of 
the  fact  at  the  time.     Besides,  it  is  not  in 
the   nature   of  things  that  one  man  can 
guarantee   himself    the    same    success    as 
another  in  adopting  his  practice,  especially 
when  that  practice  is  a  matter  of  manipu- 
lation.    And  further,  I  must  admit  such 
a  want  of  confidence  in  the  efficacy  of  the 
cautery   as    would    have    morally   inca- 
pacitated me  from  continuing  the  opera- 
tion by  such  means.     "Whether  right  or 
wrong,  then,  the  clamp   gained  its  ascen- 
dency and  I  continued  to  use  it.     It  has 
since   been    imputed    to    me   that  by  so 
doing  I  retarded  the  progress  of  ovario- 
tomy, by  deterring   others  from   A^entur 
ing  upon  an  operation  involving  a  mor- 
tality   of  1   in    4  or  5.      It    is   easy    to 
make  such  reflections  retrospectively,  and 
I  can  only  retort  that  Avithout  the  leading 
of  the  clamp  and  the  support  which  the 
clamp  results  gave  to  the  trial  of  other 
surgical   expedients,   some  of  those  Avha 
are  the  successful  ovariotomists  of  to-day 
would  never  have  been  ovariotomists  at 
all. 

The  primitive  clamp  was  nothing  more 
than  the  carpenter's  callipers.  Mr.  Hut- 
chinson introduced  them,  and  his  first  im- 
provement was  to  make  the  handles  mov- 
able. IMy  first  attempt  to  improve  upon 
this  instrument  resulted  in  the  manufacture 
of  two  lencstrated  blades,  which  were  made 
to  exert  parallel  compression  by  a  screw  at 
each  end.  After  using  this  instrument  for 
some  months  I  found  it  less  easy  of  applica- 


THE   RISE  AND  PROGRESS  OF  OVARIOTOMY 


00 


tion  than  the  modified  calliper  clamp,  and 
I  made  some  improvements  in  the  latter. 
I  found  the  most  trustworthy  was  that 
suggested  by  KUchenmeister,  of  Dresden, 
where  oblique  ridge  and  furrow  on  one 
blade  exactly  meet  the  corresponding 
elevations  and  depressions  on  the  other. 
If  properly  made,  these  surfaces,  when 
pressed  together,  will  not  allow  a  piece  of 
tine  tissue  paper  to  be  drawn  between 
them.  The  straight  instrument  lying 
awkwardly  after  application,  and  some- 
times causing  painl'ul  pressure  at  its 
angles,  I  had  it  ciu'ved  and  all  the  edges 
carefully  rounded  off.  I  substituted  I'or 
handles  a  large  pair  of  forceps  made  to  fit 
clamps  of  all  sizes.  "When  well  made  this 
instrument  holds  securely  in  most  cases 
Avherea  clamp  can  be  applied,  but  occasion- 
ally the  auxiliary  aid  of  a  ligature  is  neces- 
sary ;  for  instance,  if  the  pedicle  be  made 
up  partly  by  the  thickened  Fallopian 
tube  or  utero-ovarian  ligament,  and  partly 
by  thin  membranous  expansions  of  the 
broad  ligament  running  towards  the  colon 
or  CMCum,  the  clamp  alone  is  not  trust- 
Avorthy.  The  thin  part  of  the  pedicle  is 
not  compressed  because  the  thicker  parts 
of  the  pedicle  keep  the  blades  too  far 
apart ;  and  after  the  cyst  is  cut  away,  the 
thin  portion  of  the  pedicle  is  very  apt  to 
slip  inwards.  I  have  seen  very  trouble- 
some bleeding  arise  in  this  way,  Avhich 
might  easily  have  been  prevented  if  the 
circular  compression  of  a  ligature  had 
been  exerted  before- the  application  of  a 
clamp.  I  attempted  to  make  a  circular 
clamp,  but  I  found  that  it  would  cut 
through  some  pedicles  just  like  scissors, 
so  that  after  a  short  trial  I  returned  to 
the  use  of  the  calliper  clamp,  with  the 
modifications  which  I  have  described. 
The  mode  of  applying  the  clamp  will  be 
shown,  when  the  various  plans  of  dealing 
Avith  the  pedicle  are  considered,  in  the 
chapter  on  the  operation. 

The  introduction  of  the  extra-peri- 
toneal treatment,  as  I  have  said,  had 
more  to  do  with  the  fear  of  shutting  up 
putrefactive  matter  coming  from  the  stran- 
gulated pedicle  than  anything  else.  But 
Ave  all  at  that  time  had  an  exaggerated 
fear  of  meddling  Avitli  the  peritoneum. 
No  one  had  any  clear  notion  of  its  toler- 
ance of  everything  that  Avas  not  in  its 
nature  harmful.  IMen  Avho  had  cut  it 
open,  torn  through  adhesions  on  its  sur- 
face, and  left  it  exposed  for  perhaps  half 
an    hour   Avhile   they  Avere    liberating   a 


tumour,  Avere  anxious  to  .shut  it  up  her- 
metically as  .soon  as  they  had  finished.  I 
was  not  fir  behind  tlie  ruling  opinions, 
and  if  anyone  had  a.sked  mo  Avhy  I  united 
the  Avound  so  closely  round  the  pedicle, 
he  Avould  have  found  the  answer  in 
these  Avords  in  my  book :  '  The  fear  is  that 
peritonitis  may  be  set  up  by  leaving  any 
opening.'  It  Avas  a  curious  instance  of 
inconsistency,  because  in  the  very  .same 
page  I  advocate  a  free  opening  for  the 
exit  of  serum  if  any  there  should  be.  It 
Avasa  remnant  of  antique  superstition,  and 
Ave  liad  not  yet  fully  learnt  to  estimate  the 
eclecticism  of  the  peritoneum.  We  soon, 
however,  found  out  that  while  a  very  little 
fluid  Avhich  had  no  business  to  be  there 
irritated  as  much  as  a  .sponge,  Ave  might 
profitably  reopen,  Avash,  cleanse  and  drain. 
The  step  from  this  to  making  a  free 
passage  through  the  vaginal  Avail  was 
simple,  and  this  I  did  in  my  .36tli 
case,  thereby  saving  the  life  of  the  patient, 
AfterAvards  I  had  to  regret  sometimes  not 
having  done  it  Avith  sufficient  boldness, 
and  the  process  Avhich  came  to  be  called 
the  toilette  of  the  peritoneum,  both  primary 
and  secondary,  soon  made  progress,  and 
is  noAV  not  the  least  efficient  factor  of  the 
general  success  of  the  operation. 

Some  of  the  surgeons  Avho  had  operated 
before  me  placed  the  patient  in  a  .sitting 
posture  near  the  edge  of  the  bed,  Avith  her 
legs  Avidely  separated,  her  feet  supported 
on  stools,  and  her  back  and  head  resting 
on  pillows.  A  fcAv  do  so  still.  I  fol- 
loAved  this  practice  in  my  first  three  cases; 
but  it  Avas  so  difficult  to  keep  the  patient 
properly  covered,  she  Avas  so  apt  to  become 
faint  under  the  influence  of  chloroform, 
there  Avas  so  much  difficulty  in  preA'enting 
the  escape  of  the  intestines,  and  in  com- 
pleting satisfactorily  the  various  steps  of 
the  operation,  that  I  tried  the  recumbent 
position  in  my  fourth  case,  and  I  have 
kept  to  it  ever  since. 

Two  common  dressing-tables,  placed 
"P  fashion,  soon  commended  themselves  as 
better  than  a  special  table,  and  have 
served  me  ever  since.  The  recumbent 
position  is  incontestably  safer  for  the 
patient  as  Avell  as  more  conA'euient  to  the 
surgeon,  and  I  believe  it  is  partly  owing 
to  my  adherence  to  it  that  through  all  my 
operations  I  have  never  had  any  serious 
trouble  from  fainting  and  collapse. 

As  Avith  my  experiments  ou  animals 
so  Avith  my  patients,  I  began  closing  the 
Avound  Avitli  hare-lip  pins,  passing  them 


56 


OVAEIAN  AND  ALLIED  TUMOURS 


through  the  whole  thickness  of  the  abdo- 
minal wall  at  intervals  of  an  inch.  Each 
pin  perforated  the  skin  about  an  inch,  and 
the  peritoneum  about  half  an  inch  from 
the  incision  on  either  side,  so  that  when  tlie 
two  opposed  surfaces  "were  pressed  together 
upon  the  pin,  the  two  layers  of  peritonetmi 
■were  in  contact  with  each  other.  But  I 
soon  began  to  use  and  prefer  sutures  to 
pins,  and.  tried  different  materials  for  this 
purpose.  jNIetallic  sutures  were  then 
in  vogue,  and  in  18G1  I  was  trying 
silver.  In  18G2,  remembering  the  in- 
troduction of  platinum  sutures  twenty 
years  before  by  Mr.  Morgan  at  Guy's 
Hospital,  I  used  them  for  my  SGth 
case,  to  ascertain  if  any  advantage  Avould 
arise  from  the  employment  of  a  metal 
•which  -would  not  oxidise  like  silver  or 
iron.  But  I  have  scarcely  ever  seen  so 
much  suppiu'ation  in  the  track  of  the 
sutures  as  in  this  case ;  and  it  taught  me 
to  look  to  the  size  of  the  needle,  the  size 
and  smoothness  of  the  thread  or  silk,  the 
tightness  with  -which  it  is  tied,  and  the 
time  it  is  left,  as  having  more  to  do  with 
suppuration  or  sloughing  than  the  material 
of  which  the  sutiire  is  composed. 

Later  in  the  same  year  I  made  a  series 
of  experiments  -with  various  animal  and 
vegetable  matter.-^,  to  ascertain  their  relative 
value  as  sutures  and  ligatures,  ending  in 
a  conviction  of  the  superiority  of  good 
silk,  well  twisted,  if  tied  tightly  enough 
to  bring  the  edges  of  the  wound  together 
accurately,  yet  not  so  tight  as  to  strangu- 
late the  intervening  tissues.  Silk  need 
never  be  removed  before  the  7th  day, 
and  may  be  left  till  the  9th  or  10th,  if 
so  desired,  without  any  harm.  The  liict 
that  I  have  uniformly  used  only  silk  for 
ligatures  and  sutures  all  through  the 
several  stages  of  my  gradually  improving 
results,  shows  that  the  material  is  of  less 
importance  than  the  way  of  managing  it. 
It  was  not  long  after  changing  the  pins  for 
sutures  in  fixing  together  the  edges  of  the 
wound  that,  finding  there  Avas  a  chance  of 
suppuration  from  their  being  left  too  long, 
and  wishing  to  ascertain  how  Poon  they 
could  be  removed  with  safety,  I  adopted 
the  plan  of  supporting  the  abdominal  wall 
with  long  straps  of  adhesive  plaster,  and 
I  still  continue  to  use  them  and  a  simple 
flannel  bandage. 

In  looking  over  the  notes  of  the  period 
about  which  1  am  now  writing,  it  is  curious 
to  mark  the  vagueness  of  all  our  notions  as 
to    the  import  of  certain  symptoms  and 


conditions.  Even  such  a  point  as  the 
difference  between  reaction  and  peritonitis 
was  not  clear  to  every  one.  My  40tli 
patient  was  a  very  yoimg  woman,  who,  in 
two  years'  time,  had.  been  modelled  by 
her  disease  into  the  perfect  type  of  an 
ovarian  martyr,  and  who  rebounded  into 
health  with  a  rapidity  absolutely  marvel- 
lous when  once  relieved  from  her  oppres- 
sion. 

'  At  first  the  sudden  removal  of  such  a 
strain  seemed  to  be  almost  too  much  for 
the  system  ;  it  seemed  as  if  it  were  diffi- 
cult for  heart  and  lungs  to  play  with  even 
balance  under  so  much  lighter  a  task — the 
pulse  was  a  little  hurried,  the  face  flushed, 
the  skin  rather  hot.  But  soon  we  had  a 
free  perspiration,  and  all  went  well.  Just 
at  this  time  I  was  a  little  amused  by  the 
different  views  taken  of  the  case  by  two 
worthy  friends  of  mine.  Each  observed 
the  same  symptoms,  but  interpreted  them 
very  difFerentl3\  One,  more  at  home  in  the 
dissecting-room  and  the  dead-house  than  at 
the  bedside,  began  to  speak  ominously  of 
peritonitis,  to  suggest  leeches  and  calomel 
and  opium,  and  seemed  surprised  at  my 
being  content  to  let  what  I  thought  well 
alone.  My  other  friend,  a  true  pathologist, 
whose  life  had  been  passed  in  watching 
and  treating  disease,  saw  nothing  to  alarm 
him  in  the  quickened  pulse,  the  warm 
skin,  or  the  flushed,  face ;  he  looked, 
quite  delighted,  and  exclaimed,  "What 
nice  reaction  !  "  He  exactly  expressed 
my  own  thoughts,  and  two  small  opiates 
given  during  the  night  after  the  operation 
to  qiiiet  pain,  were  the  only  medicines  of 
any  kind  Avhich  this  patient  took  during 
her  convalescence.' 

Nor  has  her  subseqiient  career  belied 
the  good  augury  of  her  vigorous  recovery. 
She  maiTied  and  bore  children,  has  buried 
o  husbands,  and  was  in  1884  in  good 
health. 

I  have  more  than  once  had  occasion 
to  refer  to  my  4th  case,  and  I  turn  to 
it  again,  because  there  is  often  much 
practical  good  to  be  gained  by  sifting  the 
details,  or  dwelling  on  the  history,  of  an 
unfortunate  event.  I  have  said  that  I 
did  not  know  why  my  patient  died,  and 
at  the  time  that  was  quite  true.  In  the 
published  table  of  cases  the  cause  of  death 
was  set  down  as  septicaemia.  This  was 
an  after-thought.  For  what,  in  truth,  did 
any  of  us  know  about  septicaBmia  in 
1859  ?  One  may  judge  how  little  it  -was 
by  the  way  in  which  I  expressed  myself 


THE   RISE   AND   PROGRESS   OF  OVARIOTOxMY 


57 


in  a  paper  read,  before  the  Medical  and 
Cliirurgical  Society,  the  month  after  I  had 
operated. 

I  was  asking  the  meeting  to  endeavour 
to  help  me  in  estimating  the  share  which 
each  o£  four  agencies  that  I  suggested  had 
in  causing  the  deatli.     I  had  my  doubts 
about  the  opium  she  had  taken,  for  just 
then  it  was   the  custom   to  use  it  very 
freely.     I    suspected    bleeding    from   tlie 
pedicle,  at  the  moment  of  removing  the 
tumour,  might  have  done  mischief.     And 
I  was   not    disinclined   to  fortify   myself 
against  self-reproach  by  calling  to  mind 
the  collapse  which  Simpson  had  so  well 
described  as  an  accident  peculiarly  liable 
to  occur  after  operations  about  the  pelvic 
organs,  and  for  which   no  sufficient  ex- 
planation has  been   offered.     But  I  em- 
phatically   asked,     '  Did    she    die    from 
peritonitis  ?  '  adding,  '  Some  Avho  consider 
the   amount   of   lymph   effused,  and    the 
quantity  of  serum  found  in  the  peritoneal 
cavity,  would  answer  this  question  un- 
hesitatingly in    the   affirmative.      But   I 
■doubt  if  simple  peritonitis  was  sufficient 
to  cause   such   sudden   collapse.     It  was 
partial,    confined    to    the   visceral    layer 
opposed  to  the  Avounded  surface  only,  not 
dipping  down   among   the  coils  of  intes- 
tine.    My  impression  is,  that  if  peritonitis 
killed  her,  it  was  indirectly,  by  the  for- 
mation of  a  morbid  poison.     The  serum 
was   very    acrid,    it   made   Dr.    Aitken's 
hands   smart   for    some    time ;     had    he 
wounded,   himself,   in   all    probability  he 
would  have  suffered  from  morbid  poison- 
ing.   Had  he  attended  a  woman  in  labour, 
in  all  probability  tliat  woman  would  have 
had  puerperal  peritonitis.     If,  then,  my 
patient  could  generate  a  poison  capable 
of  killing  other  people,  may  it  not  have 
killed   her  ?      It    was    probably   formed 
only  from  the   inflamed  portion    of    the 
peritoneum,  the  other  portion  being  quite 
capable  of  absorbing  rapidly.'     Here  then 
was   the   idea   of   poison    superadded    to 
that  of  peritonitis ;   but  the  patient  was 
blamed  for  making  it  herself,  and  perhaps 
fairly,  as  she  had  suffered  from  an  eruj)- 
tion  of  herpes  on  one  side  of  the   chest 
only  a  feAv  days  before.      But   nothing 
was  as  yet  said  about  the  likelihood  of 
its  having  been    brought  to  her.     Two 
years  later  I  had  personal  proof  of  what 
this  poison   could  do.     I  pricked  myself 
in  examining  the  body  of  a  patient  who 
died  under  similar  circumstances,  and   I 
was  ill  enough  to  make  me  say  in  writing 


the  report  of  the  case  :  '  A  poison  which 
affected  me  so  severely  in  a  small  dose 
might  easily  kill  anyone  in  a  larger  dose. 
I  recovered  after  the  absorption  of  a 
fraction  of  a  drop ;  but  the  poor  woman 
was  overpowered  by  the  quantity  taken 
up  by  her  own  absorbents.'  Here  again 
one  part  of  the  peritoneum  was  accused 
of  distilling  and  another  part  of  absorbing 
the  venomous  fluid.  Now  I  thought  I 
had  learnt  a  grand  practical  lesson,  which 
I  reiterated  in  all  that  I  wrote,  that  our 
business  was  to  let  out  this  fluid  as  soon 
as  we  saw  signs  of  its  collecting  in  the 
peritoneal  cavity ;  either  by  opening  the 
wound  or  tapping  by  the  vagina,  or  any 
other  means  by  which  we  could  give  it 
exit.  This  policy  of  ejectment  was  very 
well  so  far  as  it  went,  and  without  ques- 
tion some  lives  were  saved  by  it.  But 
it  -was  working  at  the  wrong  end  of  the 
problem.  Still  the  missing  link  in  the 
ratiocination  of  this  subject  was  close  at 
hand.  A  parturient  woman  fulfilling  one 
of  the  natural  functions  of  life  could  not, 
except  under  the  most  abominable  con- 
ditions, be  looked  upon  as  a  focus  of 
self- engendering  poison.  Yet  she  was 
occasionally  overtaken  by  puerperal  peri- 
tonitis, and  the  cry  immediately  Avas, 
'  Where  did  it  come  from  ?  '  Importation 
was  the  accepted  explanation,  and  ac- 
coucheurs fell  into  the  category  of  '  sus- 
pected persons.'  I  had  now  the  clue  in 
my  hand,  and  in  less  than  a  year  it  led 
me  to  an  understanding  of  my  difficulties. 
Two  cases,  my  74th  and  75th,  proved 
fatal,  and  the  surroundings  were  more 
than  suspicious.  This  led  to  the 
exclusion  of  all  midwifery  practitioners 
from  my  operations  unless  they  could 
present  a  clean  bill  of  health  ;  and  subse- 
quently to  the  declaration,  so  much 
quizzed,  which  Avas  obligatory  upon  every 
person  Avishing  to  see  my  hospital  cases. 
Then  followed  other  precautions,  and  I 
Avas  to  be  seen  using  carbolic  acid  and 
the  hyposulphites  in  my  ovariotomy 
Avards. 

The  famous  asseveration  and  prophecy 
of  Sir  James  Paget  before  the  meeting  of 
the  British  Medical  Association  in  1862, 
'  that  some  of  the  deaths  after  surgical 
operations  Avere  preventible,  and  that  the 
mortality  icill  be  reduced  if  the  members 
of  the  association  Avill  decide  that  it  shall 
be,'  Avere  not  Avithout  influence.  At  the 
Cambridge  meeting  in  1864,  I  treated 
of  hospital  atmosphere,  organic  germs  as 


oS 


OVAFJAX   AND   ALLIED   TUMOURS 


causes  of  excessive  mortality,  and  com- 
mented on  the  researches  of  PoUi  with 
sulphur  and  the  sulphites.  Here  then 
were  theory  and  practice  brought  into 
accord,  and  my  quarantine,  spongings, 
pads,  "Nvool,  drainage,  vaginal  tappings,  and 
chemical  remedies  combined  the  essentials 
of  antiseptic  treatment. 

The  progress  of  ovariotomy  in  Eng- 
land has  thus  been  brought  to  the  issue 
of  my  first  book  at  the  end  of  the  year 
1864.  It  is  a  simple  record  of  what  I 
did,  of  the  oscillating  opinions  on  many 
points  of  practice,  of  the  way  in  which 
light  dawned  upon  some  of  the  obsciirities 
of  the  subject,  of  the  anxious  unravelling 
of  some  of  the  mixed  threads  of  logic  and 
experiment  which  led  to  definite  lines  of 
action,  of  the  discussions,  consultations, 
and  W'orkings  with  a  great  number  of 
estimable  and  accomplished  men.  As 
none  of  my  cases  have  since  been  so  fully 
described,  it  even  now  serves  as  a  wreck- 
chart  and  a  guide. 

During  the  seven  years  and  a  half 
which  succeeded,  I  completed  500 
cases  of  ovariotomy,  and  in  the  au- 
tumn of  1872  published  my  book  on 
ovarian  disease.  I  still  continued  to  do 
the  surgical  Avork  of  the  hospital,  having 
been  all  through  assisted  by  a  succession 
of  younger  colleagues,  among  whom  I 
may  mention  especially  Charles  Ritchie, 
Junker,  and  W.  Thomson.  The  promis- 
ing career  of  Ritchie,  to  my  great  regret, 
was  cut  short  by  a  melancholy  accident, 
and  both  Junker  and  Tliomson  have  seized 
opportunities  of  distinguishing  themselves 
otherwise  than  as  ovariotomists.  It  Avas 
during  this  time  that  Dr.  Richardson 
brought  to  my  notice  methylene  as  an 
anaesthetic,  and  Junker  invented  an  ap- 
paratus, for  its  convenient  administration, 
Avhich  has  been  in  use  ever  since.  Chloro- 
form liad  been  given  from  the  first  with 
the  exception  of  a  few  trials  of  ether  and 
other  combinations,  but  it  was  quite 
supjilanted  by  methylene.  By  its  use  we 
have  been  spared  the  anxiety  and  danger, 
and  most  of  the  annoyances  which  so  often 
attend  the  employmentof  other  anaesthetics. 

The  work  of  ovariotomy  Avas  noAv 
becoming  a  matter  of  routine.  Series  of 
hundreds  succeeded  to  series  of  hundreds, 
and  Avith  reguhu'ly  diminishing  losses. 
Instruments  v/ere  new-modelled,  and 
there  Avere  modifications  of  manipulative 
details  and  after-treatment,  but  Ave  Avere 
now  acting  upon  principles  Avhich  kept  us 


pretty  nearly  in  a  given  course,  and  made 
the  service  of  the  sick-room  compara- 
tively easy.  Dr.  Bantock  and  Mr. 
Thornton  Avere  installed  as  joint  surgeons 
Avith  me  in  hospital,  and  not  only  took  a 
part  in  my  operations,  but  commenced 
their  oAvn  Avork  as  ovariotomists  in  IS?.") 
or  1876. 

The  incident  of  Lister's  arrival  in 
London  in  the  year  1877  raised  the 
question  of  the  applicability  of  his  sys- 
tem to  ovariotomy.  The  mortality  from 
my  OAvn  hospital  operations  being  at  this 
time  not  much  more  than  9  per  cent.,  I 
hesitated  about  venturing  upon  any  un- 
tried proceedings  Avhich  might  interfere 
Avith  results  so  satisfactory.  But  jNIr. 
Thornton  introduced  Listerian  practice 
in  all  its  integrity  at  the  Samaritan, 
and  Dr.  Bantock  for  a  time  folloAved  his 
example.  Some  other  novelties,  such  as 
Dr.  Bantock's  non-alcoholic  after-treat- 
ment and  Mr.  Thornton's  ice-cap  a  little 
diversified  the  routine  of  our  Avards. 

After  20  years'  service  as  ope- 
rating surgeon  to  the  Samaritan  Hospital 
I  felt  myself  not  only  Avarranted  in  re- 
tiring, but  bound  to  make  Avay  for  my 
junior  colleagues,  and  at  the  end  of  the 
year  1877  placed  my  resignation  in  the 
hands  of  the  committee.  At  their  re- 
quest, hoAvever,  I  retained  the  post  of 
consulting  suigeon.  My  last  ovariotomy 
as  surgeon  to  the  hospital  Avas  done  on 
December  12,  and  after  it  I  made  a  few 
remarks  to  those  present,  giving  a  sum- 
mary of  my  Avork  in  these  cases.  The 
following  table  shoAved  the  distribution  of 
my  hospital  operations  over  these  20  years: 


Years 

Cases 

Recoveries 
3 

Deaths 

1858 

3 

0 

1859 

G 

4 

2 

1 8<)0 

2 

1 

1 

18fil 

G 

;j 

3 

ISC.  2 

1.3 

10 

3 

lK(;;j 

IG 

11 

5 

1SG4 

14 

11 

3 

1865 

17 

13 

4 

18G6 

15 

10 

5 

1H67 

'21 

17 

4 

ISGS 

t\2 

25 

7 

]8G'.) 

21 

14 

7 

1870 

24 

17 

7 

1.S71 

2G 

18 

,s 

1872 

30 

23 

7 

1873 

Hi 

115 

9 

1874 

29 

20 

9 

187.") 

28 

20 

8 

187G 

42 

o8 

4 

1877 

29 

26 

3 

Total     . 

408 

309 

99 

' 

- '' 

THE   PJSE   AND  PllOGRESS   OF  OVAEIOTOMY 


59 


Another  table,  dividing  the  20  years 
into  4  successive  periods  of  5  years 
each,  gives  at  once  tlie  number  of  cases, 
the  nuinlier  of  deaths,  and  the  percentage 
of  recoveries  : 


Dates     of  Comi-letion    of    tiik    successive 

HLNI)Ur,DS       OF       OVAUIOTOMY        OpKKATIOXS 
FIIOM    IHoS  TO   1880 


Series  of  years 


First  five  years  (1858 

to  18G2)  .... 
Seconrl  five  years(18G3 

to  l«(i7)  .... 
Third  five  years  (18G8 

to  I.S7-2)  .  .  .  . 
Fourth  live  years  (187o 

to  1877)      .     .     .     . 

Total     .     .     .     . 

Last  two  vears   (1.S7G 
and  187/)  ,    .     .    . 


Cases 

Is 

p 

30 

9 

83 

21 

133 

3G 

102 

33 

99 

408 

71 

7 

llccovcries 


70  per  cent. 
74        „ 
73        „ 
80        „ 

90 


It  appears  from  this  that  in  the — 

about  1  in   3  died 
,,     1  „   4     „ 
„     1  „   5    „ 
„     1  „  10     „ 


First  5  years 

Second  and  third  5  years 

Fourth  5  years 

Last  2  years 


A  moment's  consideration  of  these 
figures,  showing  the  changing  proportion 
between  recoveries  and  deaths  as  time 
went  on,  will  carry  the  conviction  that 
increasing  experience  had  been  accom- 
panied by  diminishing  mortality ;  and 
enabled  me  in  the  last  years  of  my  prac- 
tice in  the  hospital,  Avith  a  return  of 
90  per  cent,  of  recoveries  after  operation, 
to  set  up  a  standard  of  success  far  beyond 
what  we  had  reason  to  hope  for  under  the 
conditions  of  a  London  institution.  The 
way  in  which,  my  successors  have  carried 
on  the  operative  work  justifies  the  course 
I  took  in  leaving  it  in  their  hands,  and 
makes  it  clear  that  the  patients  have  no 
cause  to  regret  the  change. 

The  four  years  from  1878  to  1881 
were  memorable  to  me  for  two  reasons : 
that  during  them  I  completed  1,000 
cases  of  ovariotomy  ;  and  that  I  took  up 
the  antiseptic  system  adopted  elscAvhere, 
so  as  to  judge  by  my  own  experience,  not 
of  its  general  scientific  claims,  but  of  the 
utility  of  the  Lister  spray  and  dressings 
in  abdominal  surgery. 

My  exclusively  private  practice  began 
January  1878  with  the  888th  case,  and 
in  the  month  of  June  1880  the  number 
of  1,000  cases  was  made  good.  The 
table  which  I  annex  notes  in  detail  the 
times  in  Avhich  the  several  series  of  hun- 
dreds were  accumulated  and  other  mat- 
ters connected  Avitli  them  which  have  a 
statistical  interest. 


No. 


Dates 


1  From  Feb.  1S58  to  .Tune  1864 

2  „  June  1 8G1  „  Mar.  1867 

3  „  Mar.  18U7  ,,  .Jan.  1869 

4  I  .,  Jan.  18G9  „  Dee.  1870 
.o!  „  Dec.  1870  „  June  1872 
G  I  „  June  1872  „  Jan.  1874 

7  1  „  Jan.  1874  „  Apr.  1875 

8  .,  Apr.  I.s7r)  „  Oct.    187G 

9  „  Oct.  187(1  „  June  1><78 
10  „  June  1878,,  June  1880 


B 


100 
100 
100 
100 
100 
100 
100 
100 
100 
100 


768  232  i  1,000 


General  mortality,  23-2  per  cent. ;  largest  34, 
smallest  11. 

The  Avhole  time  occupied  was  22  years  and  5 
months. 

Before  touching  upon  the  question  of 
what  influence  the  so-called  '  antiseptic 
precautions '  or  details  of  the  Listerian 
method  have  had  upon  my  results,  I 
Avill  explain  to  what  extent  their  adop- 
tion Avas  an  addition  to  my  previous 
practice. 

Long  before  Lister  had  tried  any 
of  his  methods,  indeed  from  the  very- 
beginning  of  my  practice  of  ovariotomy, 
I  had  insisted  upon  all  possible  care  in 
protecting  patients  before,  during,  and 
after  operation  from  all  the  known  causes 
of  excessive  mortality  ;  and  I  took  un- 
usual precautions  against  any  risk  of 
contagioxis  or  infectious  disease  being 
communicated  to  a  patient,  and  against 
the  entrance  from  without,  or  the  develop- 
ment from  Avithin,  of  anything  Avhich 
could  set  up  traumatic  fever  or  blood- 
poisoning.  I  contended  that  obstetrics 
and  operative  surgery  should  seldom  be 
permitted  in  the  same  building,  or  by 
the  same  surgeon  in  private  practice  ;  and 
that  such  an  operation  as  ovariotomy 
should  never  be  performed  Avhere  patients 
with  uterine  cancer,  or  offensive  dis- 
charges of  any  kind,  may  pollute  the 
place.  Li  1875,  a  separate  branch  of  the 
Samaritan  Hospital  Avas  opened,  and  since 
that  year  the  surgical  Avards  have  been 
much  freer  from  such  sources  of  danger. 
The  good  effects  of  this  change  Avere 
noted  before  other  antiseptic  measures  Avere 
insisted  on,  and  to  such  an  extent  that 
the  death  rate  after  my  operations  Avas 
reduced  by  one- half.  And  cleansing  or 
purification  of  the  Avard  or  room,  of 
everything  about  the  operating  table  and 


60 


OVARIAN  AXD  ALLIED  TUMOURS 


bedding,  of  the  patient  herself  and  the 
parts  near  the  seat  of  operation,  of  the 
surgeon,  assistants,  and  nurses,  and  of  all 
the  instruments,  sponges,  and  water  used, 
had  been  rigidly  enforced,  before  carbolic 
acid  was  used,  or  any  antiseptic  precavition 
added  to  those  adopted  before  1878. 

As  the  material  for  tying  vessels  and 
limiting  the  Avound,  the  same  pure  twisted 
silk,  unmixed  with  any  vegetable  fibre, 
which  I  have  trusted  to  for  about  20 
years  has  been  used.  Various  forms  of 
quilled  and  twisted  sutures  have  been 
tried  and  abandoned.  But  since  1878, 
all  the  silk  for  ligatures  and  sutures  has 
been  soaked  before  use  in  a  5  per  cent, 
solution  of  carbolic  acid  or  phenol.  I 
have  not  always  boiled  the  silk,  as  Bill- 
roth and  others  have  done. 

Dry  dressing  of  the  wound  has  been 
continued ;  but  in  place  of  the  pads 
formerly  used,  of  5  per  cent,  of  oil  of  tar 
•vrith  95  per  cent,  of  chalk,  either  thymol 
or  iodoform  gauze,  or  cotton  pads  charged 
with  borax  or  phenol,  have  been  used. 
These  are  more  comfortable  to  the  pa- 
tient, and  are  better  absorbents  of  mois- 
ture. As  a  rule  they  are  not  touched 
before  the  seventh  or  eighth  day,  when 
the  sutures  are  removed,  and  the  wound 
is  almost  invariably  found  to  be  com- 
pletely united. 

The  two  most  important  additions  to 
previous  antiseptic  precautions  are,  first, 
■carbolising  the  sponges  and  instruments, 
and  secondly,  the  use  of  the  spray.  I 
had  long  insisted  on  the  great  import- 
ance of  always  using  sponges  perfectly 
purified  Avith  sulphurous  acid ;  and  after 
<in  operation  I  continue  my  old  plan  of 
keeping  the  cleansed  sponges  in  a  weak 
solution  of  sulphurous  acid.  And  during 
the  operation,  in  addition  to  washing  in 
jmre  Avater,  every  sponge  before  iise  is 
•wetted  Avith  a  2  to  3  per  cent,  solution  of 
•carbolic  acid  or  absolute  phenol.  Soft 
clean  linen  cloths,  Avetted  with  a  Avarm 
solution  of  phenol,  may  be  used  to  lessen 
the  number  of  sponges  required ;  and 
(nurses  must  be  cautioned  not  to  put  any 
•of  the  soiled  sponges  into  the  solution 
imtil  after  they  have  been  washed  Avith 
pure  Avater,  otlierwise  albumen  may  be  so 
■coagulated  as  to  prevent  thorough  cleans- 
iog.  As  nurses  often  fall  into  this  eri'or, 
it  is  well  to  have  two  or  three  difierent 
sets  of  sponges,  all  carefully  numbered, 
(kept  separate  for  the  successive  steps  of 
the  operation. 


Nearly  all  my  instruments  used  in 
ovariotomy  are  protected  from  rust  by  a 
coating  of  nickel.  They  are  then  more 
easily  and  thoroughly  cleaned  after  use, 
and  the  cleaned  instruments  should  be 
placed  before,  and  replaced  during  the 
operation,  in  trays  or  dishes  filled  with  a 
Avarm  solution  of  phenol. 

These  additional  precautions  as  to 
sponges,  silk,  and  instruments,  I  believe 
to  be  really  important.  I  have  been 
always  doubtful  about  the  spray.  '  Striv- 
ing to  better,  oft  Ave  mar  Avhat's  Avelh' 
In  prolonged  operations,  I  have  had  reason 
to  fear  that  its  chilling  effect  upon  the 
patients  has  been  injurious.  But  I  have 
never  once  seen  any  other  ill  effect  Avhich 
I  could  attribute  to  it,  nor  anything  like 
carbolic  poisoning.  The  misty  cloud 
occasionally  obscures  the  field  of  opera- 
tion, but  not  to  an}'  serious  extent,  and  it 
is  always  easy  to  protect  the  peritoneal 
cavity  against  the  continued  action  of  the 
spray  by  a  large  Avarm  sponge.  After  a 
foAv  trials  I  gave  up  thymol  spray  as  use- 
less, and  for  more  than  four  years  past 
have  used  a  spray  of  absolute  phenol  of 
a  strength  of  one  in  forty.  This  I  con- 
tinue to  use,  belieA'ing  it  to  be  safer  than 
the  irrigation  or  sponging  proposed  as 
substitutes.  We  require  a  far  greater 
number  of  trustworthy  experiments,  or 
of  comparative  observations,  made  under 
similar  conditions  with  and  Avithout  spray, 
than  have  yet  been  made  knoAvn,  before 
Ave  can  receive  any  satisfactory  ansAver  to 
the  questions  Avh ether  carbolised  A-apour 
or  air  can  destroy  or  render  innocuous 
infective  or  putrefactive  substances  or 
germs  floating  in  the  air ;  or  what  is  the 
share  Avhich  the  spray,  among  other  addi- 
tional antiseptic  precautions,  has  had  in 
obtaining  the  better  results  Avhich  have 
undoubtedly  accompanied  their  combined 
employment. 

The  only  modification  in  the  mode  of 
operation  Avhich  calls  for  further  remark 
is  the  very  much  more  frequent,  almost 
constant,  employment  of  the  intra-'peTi- 
toneal  treatment  of  the  pedicle  since  the 
trial  of  the  antiseptic  system  Avas  begun. 
For  several  years,  the  extra-peritoneal 
treatment  Avas  by  far  the  more  success- 
ful in  my  practice.  When  comparing 
the  results  of  the  two  methods  at  the 
College  of  Surgeons  in  June  1878,  I 
shoAved  that  of  027  e.r^ra-peritoneal  cases, 
130  had  died,  or  2073  per  cent.,  while  of 
157  t«<ra- peritoneal  cases,  GO    died,  or 


THE   RISE  AND   PROGRESS  OF   OVARIOTOMY 


61 


3S'2  per    cent.,    the   mortality  with  the  ! 
ligature  having  been  nearly  double  that  ! 
with  the  clamp.     Latterly  this  disparity  1 
disappeared,  and  the  results  from  the  two 
modes  of  treating  the   pedicle  were  about  ' 
equal.      I  am  quite  sure  that,  as  has  been  ! 
suggested,    the    f.r^/'a-peritoneal    did    not  : 
represent    the    simple,    and    the     infra-  \ 
peritoneal  the    complicated,    cases.     The  i 
difference   was    simply    that    of    long    or  ' 
short  pedicle.     Whenever  the  pedicle  was 
long  enough,  I  used  to  employ  a   clamp 
whatever  might  be  the  complications  of 
the  case  ;  and  in  short  pedicles  I  used  the  '• 
ligature  or  cautery,  Avhether  the  case  was 
otherwise  simple  or  the  reverse.     Before 
antiseptic   treatment    was   generally   fol- 
lowed,    septic    changes,    which   are   now 
scarcely   ever  observed,   frequently   took 
place  in  or  about  the  tied  pedicle.     Since 
the  additional  antiseptic  precautions  have 
been  adopted  the  many  disadvantages  of 
the  ea;/ra-peritoneal  method,  Avhich  were 
only  counterbalanced  as  long  as  greater 
success    lasted,    have    no    longer    to    be 
endured. 

Another  great  gain  from  the  anti- 
septic system  is  that  drainage  of  the 
peritoneal  cavity  is  now  scarcely  ever 
necessary.  In  the  paper  which  I  brought 
before  the  Medical  and  Chirurgical  So- 
ciety in  1876  on  completing  800  cases,  I 
contended  that  drainage  should  only  be 
an  exceptional  practice.  But  I  did  not  then 
imagine  that  it  could  be  almost  entirely 
discarded.  I  can  now  say  that  I  have  not 
di-ained  one  case  in  which  antiseptic  pre- 
cautions have  been  taken ;  and  on  look- 
ing back,  I  cannot  believe  that  there  are 
more  than  two  or  three  in  which,  if  a 
drainage  tube  had  been  used,  it  could 
have  been  useful.  The  simple  explana- 
tion is,  that  the  mixture  of  blood,  other 
fluids  and  air  left  in  the  peritoneal 
cavity,  or  oozing  into  it  after  operation, 
formerly  went  through  putrefactive 
changes,  and  if  not  drained  off  produced 
septictemia,  whereas  now  no  putrefaction 
takes  place,  and  absorption  is  quite 
harmless. 

I  now  come  to  the  question  of  results. 
The  great  hindrance  to  the  success  of  the 
operation  was,  in  1878,  the  same  as  it 
had  been  20  years  before,  when  B.  Brown 
quailed  before  what  he  called  peritonitis, 
but  which  we  have  since  learned  was  really 
the  frequent  occurrence  of  blood  poison- 
ing. The  difference  in  respect  to  this 
matter  was  that  that  which  formerly  scared 


us  as  an  incomprehensible  mystery,  was  by 
1878  in  a  great  measure  understood.  We 
began  to  see  what  septicajmia  meant,  and 
how  it  reached  our  patients.  Various  pre- 
cautions had  bettered  the  situation,  but 
the  evil  Avas  still  formidable.  This  Avili 
be  seen  by  looking  at  my  returns  for  the 
years  187G-77.  In  those  2  years  I  did 
152  operations,  including  both  hospital  and 
private  patients,  and  had  29  deaths.  This 
gives  a  mortality  of  18"4.  But  of  those 
29  deaths,  only  5  were  accidents  of  the 
operation  which  we  may  in  some  pro- 
portion be  sure  or  encountering,  such  as 
haemorrhage,  shock  or  cancer.  So  that 
20  years'  experience  may  fairly  be  said 
to  have  reduced  the  mortality  of  the 
operation  upon  my  uncontaminated  pa- 
tients to  3 "6  per  cent.  The  remaining 
24  deaths  were  caused  by  septicaemia,  a 
mortality  of  15"8  per  cent.  71  of  these 
152  patients  were  in  the  hospital.  Of 
these,  7  died,  all  from  septicaemia.  There 
were  no  deaths  among  them  really  attri- 
butable to  the  operation.  All  were  from 
contagion,  and  but  for  that  would  have 
recovered.  Among  my  81  private  cases 
during  the  same  time,  5  deaths  were 
more  or  less  directly  connected  with  the 
operation,  and  17  were  from  communi- 
cated septicajmia.  This  shows  how  the 
success  of  ovariotomy  was  marred  at  that 
time  by  the  great  evil  which  till  then 
had  persistently  attended  it.  Still  as  an 
operation  which,  when  done,  either  failed 
to  save  life,  or  was  fatal  to  the  extent 
of  18'4<  per  cent.,  ovariotomy  was  worth 
doing.  But  when  I  could  show  by  my 
experience  that  the  operation  could  be 
done  on  patients,  if  screened  from  the 
effect  of  contagion,  with  a  loss  of  only  froni 
3  to  4  per  cent.,  it  became  an  imperative 
obligation  to  seek  out  some  means  of  giving 
patients  all  the  benefit  of  further  antiseptic 
measures.  The  microbe  to  which,  either 
as  spore  or  vibrio,  septicaemia  had  been 
experimentally  traced,  was  like  any  other 
beast  of  prey,  to  be  exterminated  or  held 
in  subjection.  These  infinitely  small  beings, 
existing  everywhere,  and  multiplying  with 
'  a  rapidity  which  defies  calculation,  could 
;  not  be  dealt  with  like  wolves  or  poisonous 
;  reptiles.  That  was  out  of  the  question, 
and  the  alternative  was,  if  possible,  to- 
;  prevent  their  access  to  our  patients ;  or,. 
j  failing  on  that  point,  to  put  our  patients= 
in  such  a  condition  that  they  did  not  afford 
I  a  nidus  favourable  for  multiplication.  The 
•  mature  vibrios  offered  no  great  difficulties^ 


62 


OVARIAN   AND   ALLIED   TUMOURS 


They  are  anaerobic,  and  will  not  live  either 
in  air  or  acid.  But  the  spores  are  aerobic, 
■with  a  much  stronger  vitality,  and  may 
be  looked  upon  as  the  arch-enemy.  By 
force  of  circumstances  ^ye  are  obliged  to 
pass  over  the  point  of  defence  from  in- 
vasion, and  to  restrict  our  efforts  to  the 
accumulation  of  all  hindrances  to  de- 
velopment in  the  body  to  which  they  find 
access.  Pasteur  had  already  indicated,  in 
a  general  way,  what  shovild  be  done  with 
the  sick  and  all  that  pertains  to  them. 
Lister  presented  to  us  his  system  as  effi- 
cient, and,  as  I  have  shown,  I  have  now 
for  7  years  adopted  all  that  he  sug- 
gested, in  addition  to  my  own  habitual  pre- 
cautions. I  have  used  the  carbolic  spray  ; 
but  I  have  never  attached  much  import- 
ance to  it,  except  that  it  tends  to  general 
cleanliness,  and  may  sometimes  carry  its 
influence  into  parts  which  would  other- 
wise be  overlooked  or  inaccessible,  so 
as  to  prevent  the  formation  of  suitable 
niduses  for  the  propagation  of  the  spores 
of  the  septic  microbe.  I  have  systema- 
tically passed  everything  used  in  the 
operations  through  the  carbolic  solution, 
have  used  it  for  myself  and  assistants, 
and  have  as  much  as  possible  enforced 
washings  with  it  upon  the  nurses. 

The  dressings  of  carbolic  or  thymol 
gauze,  and  boracic  wool,  have  proved  satis- 
factorv,  as  well  as  convenient,  and  latterly 
salicylic  wool  has  been  pat  on  in  abund- 
ance. Every  antiseptic  principle  has  been 
kept  in  view  during  the  after-treatment. 
There  may  have  been  some  shortcomings 
in  the  details  of  my  Listerian  work,  ac- 
cording to  the  notions  of  a  few  enthusiasts ; 
but  upon  the  whole  it  has  been  as  practi- 
cally complete  as  it  is  in  the  power  of  any 
surgeon  not  a  mere  dilettante  to  make  it. 
What  has  happened  in  these  7  years  is 
satisfactory;  but  how  far  it  can  be  called 
the  result  of  antiseptic  treatment,  and  how 
much  is  due  to  other  coincident  changes, 
must  always  remain  uncertain.  The  lacts, 
however,  are  these.  From  January  1878 
to  the  end  of  1884,  in  private  practice 
only,  I  have  completed  ovariotomy  in  247 
cases,  with  a  loss  of  27  patients,  making  a  I 
mortality  of  109  per  cent.  If  I  compare 
these  figures  with  those  of  my  last  2 
years  of  hospital  work,  it  would  seem  that 
no  change  of  importance  had  taken  place, 
that  ovariotomy  could  be  done  as  success-  ' 
fully  without  as  with  antiseptic'*,  since  the 
difference  of  1  per  cent,  in  the  mortality  j 
might  be  accidental.     But  if  I  take  the  , 


'  whole  152  cases  in  the  years  1876-77, 
with  their  mortality  of  18'4  per  cent.,  and 
place  them  against  my  247  subsequent 
j  cases,  there  comes  out  at  once  a  change 
for  the  better  of  more  than  7  per  cent,  in 
the  result.  This  is  soraething,  but  it  might 
be  accounted  for  otherwise  than  by  anti- 
septic influences.  Then  if  I  go  still  further, 
and  make  it  a  question  of  relative  mor- 
tality from  contagion ;  if  I  investigate  not 
only  the  fact  of  death,  but  the  cause  of 
death,  the  question  assumes  another  aspect. 
In  the  2  years  1876-77.  out  of  29  deaths, 
there  were  24  from  septica3raia,  whereas  in 
the  7  following  years,  out  of  27  deaths, 
only  10  could  be  placed  to  that  cause. 
Here  we  seem  to  have  proved  that  anti- 
septics had  done  a  great  deal ;  for  if  the 
old  ratio  of  septicajmia  had  continued, 
namely,  in  the  proportion  of  1  case  of 
death  from  it  after  every  6  operations,  I 
ought  to  have  seen,  in  the  following  7 
years,  among  my  247  operations,  at  least 
40  cases  of  septicaemia.  Again,  if  I  ab- 
stract the  7  hospital  cases,  and  calculate 
only  on  the  17  which  happened  among 
the  81  private  cases  in  1876-77,  the 
number  of  cases  which  would  have 
occurred  in  the  following  7  years,  in 
the  same  proportion,  would  have  been  49 
or  50.  That  is  to  say,  I  had  passed  7 
years,  and  done  247  operations  with  a  mor- 
tality from  septicaemia  of  only  10  cases, 
instead  of  the  50  which  I  should  have  had 
to  deal  with  if  the  proportion  of  1876-77 
had  been  kept  up. 

If  there  were  no  other  points  to  be 
considered  besides  those  involved  in  mere 
figures,  a  difference  of  mortality  to  this 
extent  would  be  decisive,  and  I  am  ready 
to  admit  that  the  Listerian  additions  to 
my  precautions  have  been  in  many  respects 
eminently  serviceable.  I  am  further  con- 
vinced that  by  the  use  of  antiseptics,  espe- 
cially of  phenol,  those  patients  who  have 
recovered  have  suffered  much  less  from 
fever,  Avhile  convalescence  has  been  more 
rapid  than  it  used  to  be.  Formerly  tem- 
peratures of  100"^  to  lOo''  were  usual,  and 
104°  to  107°  not  very  uncommon.  And 
the  head  was  cooled  by  ice  in  at  least  half 
the  cases.  Now  cold  to  the  head  is  scarcely 
ever  thought  of,  certainly  not  used  in  1 
case  in  20,  and  a  temperature  of  102°  is 
rare.  Recovery  Avith  a  temperature  which 
never  ri.ses  above  100°  is  the  rule.  This 
alone  is  an  important  step  in  advance, 
especially  as  it  affects  the  well-being  of  a 
great  majority  of  the  patients,  and  for  those 


THE   RISE   AND  PROGRESS  OF  OVARIOTOMY 


63 


in  hospitals  lessens  considerably  the  cost 
of  their  maintenance.  I  have  never  felt 
any  inconvenience  myself,  nor  have  I  seen 
any  of  my  patients  suffer  from  carbolic 
poisoning.  Still  as  other  surgeons  have  en- 
countered that  double  objection,  it  must 
be  taken  into  account,  as  well  as  the  de- 
pressing influence  of  the  cold  spray  on  a 
sick  woman  prostrated  by  anesthetics,  and 
the  inconvenience  caused  by  its  inter- 
ference with  light.  We  may,  however, 
give  up  the  spray  without  abandoning  the 
principle  of  Listerism,  or  the  most  impor- 
tant details  of  the  practice.  So  far  as  the 
operation  itself  is  concerned,  independent 
of  its  giving  access  to  microbes  or  their 
spores,  I  do  not  sec  that  Listerism  can 
have  much  influence.  It  does  not  render 
the  manipulation  either  more  or  less  diffi- 
cult, nor  does  it  in  any  way  diminish  the 
chance  of  the  accidents  common  to  all 
capital  operations.  But  with  regard  to 
septicPemia,  even  though  we  cannot  pro- 
portion the  effect  of  the  coincident  causes, 
the  diminution  which  I  have  recorded  as 
having  taken  place  in  my  last  7  years'  ex- 
perience is  a  most  happy  result. 

Much  may  be  due  to  antiseptic  dress- 
ings, and  to  the  persistent  diffusion  of  an 
antiseptic  atmosphere ;  but  it  must  be 
remembered  that,  at  the  same  time,  my 
patients  since  1878  have  all  had  not  only 
the  advantages  belonging  to  a  position  in 
life  above  that  of  hospital  cases,  but  they 
have  been  exempt  from  the  risks  of  the 
possible  importation  of  hospital  contagion. 
The  abandonment  of  the  clamp,  and  the 
use  of  the  ligature  with  the  intra-peri- 
toneal  treatment  of  the  pedicle,  took  place 
at  the  same  time  as  the  introduction  of 
the  antiseptic  treatment;  and  since  1878 
I  have  never  put  a  drainage  tube  into  any 
peritoneal  cavity.  Then,  too,  as  an  addi- 
tional security  to  my  patients,  I  have 
never  made  a  post-mortem  examination, 
have  been  free  from  all  but  the  most 
casual  contact  witli  hospital  influences, 
have  never  carried  about  Avith  me  the 
infections  picked  up  in  general  practice, 
and  having  had  fewer  persons  present 
at  my  operations,  have  eliminated  a  great 
part  of  an  incalculable  soiirce  of  danger. 
Still  after  all,  this  plngue  of  abdominal 
surgery  is  not  abolished,  and  Listerism 
has  not  l:>rought  me  to  the  point  of  seeing 
no  deaths  from  septicajmia.  There  yet 
remains  a  contingent  mortality  of  4  per 
cent,  from  septicaBmia  which  must  be  got 
rid  of,   and   carbolic  acid  does  not  seem 


likely  to  do  it.  These  microbes  all  have 
their  peculiarities,  and  perish  or  flourish 
under  the  most  unexpected  conditions. 
What  Ave  Avant  now  to  knoAV  is,  the  agent 
we  can  employ  in  surgery  Avhich  is  lethal 
to  the  microbe  or  spore  of  septicaemia, 
and  not  injurious  to  patient  or  surgeon. 
Or  can  Ave  look  to  tlie  possibility  of 
protective  inoculation  Avith  an  attenuated 
virus  ? 

Resuming  our  survey  of  the  history 
and  progress  of  ovariotomy  since  its 
revival  in  Great  Britain,  I  must  refer  to 
a  letter  ivritten  by  Dr.  Keith  on  Decem- 
ber 17,  I.S.S4,  in  which  he  informs  me 
that  his  number  of  ovariotomy  cases  Avas 
then  490.  Of  these  4.5  died,  showing  a 
death  rate  of  911  per  cent. 

Dr.  Keith  adds  that  his  son  has 
had  37  ovariotomies  Avith  only  1 
death ;  and  I  most  cordially  AAish  him 
the  same  increasing  success  that  has  re- 
Avarded  the  skill  and  judgment  of  his 
father. 

We  have  now  to  folloAv  the  advance 
of  the  operation  in  France,  Belgium, 
Germany,  Russia,  Italy,  and  Spain,  and 
in  America  and  our  colonies,  although 
any  such  revicAV  must  necessarily  be  brief 
and  imperfect. 

In  France,  ovariotomy  made  but 
tardy  progress.  Nor  was  this  to  be  Avon- 
dered  at,  Avhen  Ave  find  a  man  like  Vel- 
peau  opposing  it  in  1847  ;  and  that,  not- 
Avithstanding  Cazeaux's  spirited  and  ener- 
getic advocacy,  the  Academic  de  Medicine 
condemned  it  in  1856.  A  paper  by  Dr. 
Worms,  in  1860,  had  hoAvever  a  better 
result.  Dr.  Worms's  paper  Avas  founded 
upon  an  examination  of  some  of  my 
OAvn  early  cases.  He  took  the  precau- 
tion of  writing  to  the  medical  attendants 
of  the  patients,  in  order  to  ascertain 
their  condition  from  the  time  of  opera- 
tion up  to  the  date  of  his  paper,  and  this 
able  advocacy  attracted  very  general 
attention  in  France.  Perhaps  its  most 
important  effect  was  to  induce  M. 
Nelaton  to  visit  England  for  the  pur- 
pose of  Avitnessing  the  operation,  and 
studying  its  details.  He  Avas  here  in 
1862,  and  Avitnessed  several  operations. 
He  assisted  me  at  one  A-ery  complicated 
case,  Avhich  terminated  successful! v,  and 
Avas  much  interested  in  another  Avhere 
tetanus  proved  fatal.  On  his  return  to 
Paris,  he  operated  himself,  and  published 
a  classical  clinical  lecture,  from  Avliich 
may  be  dated  the  reA'ival  of  ovariotomy 


G4 


OVARIAN  AND  ALLIED   TUMOURS 


in  France.  Koeberle,  of  Strasburg,  per- 
formed his  first  operation  in  18G2,  which 
was  also  the  date  of  Nelaton's  first  opera- 
tion. It  had  certainly  been  performed  in 
France  before  Nelaton's  visit  to  England. 
The  first  case  was  in  1844,  by  a  country 
surgeon,  Dr.  Woyerkowski,  of  Quingez. 
This  case  may  be  looked  upon  rather  as 
an  accidental  than  an  intentional  ova- 
riotomy. The  next  case  was  in  1847, 
Avhen  another  country  surgeon,  M.  Vaulle- 
geard,  of  Conde-sur-Noireau,  operated 
successfully.  Since  18G2,  the  example  of 
Nelaton  in  Paris,  and  the  influence  of 
Boinet,  followed  by  the  many  successful 
operations  of  Pean,  have  done  much  for 
the  operation  of  ovariotomy  in  France ; 
but  the  larger  experience  of  Koeberle, 
of  Strasburg,  has  probably  had  even  a 
still  greater  effect. 

Eustache,  of  Lille,  reports  Koeberle 
to  have  had  more  than  320  operations 
early  in  1881.  Pean  sent  me  his  report 
up  to  the  month  of  October  1881.  His 
gastrotomies  then  amounted  to  449 ; 
306  of  these  were  for  the  removal  of 
ovarian  cysts,  with  245  recoveries  and 
(Jl  deaths.  But  it  has  been  the  same 
with  Pean  as  Avith  most  other  surgeons. 
His  latest  work  is  his  best,  for  out  of 
the  last  100  ovariotomies  there  have  been 
only  14  bad  results;  and  curiously 
enough,  exactly  7  in  each  of  the  last  two 
fifties. 

I  believe  I  was  the  first  to  perform 
ovariotomy  in  Belgiimi,  in  July  1865,  in 
the  chief  hospital  at  Brussels,  upon  a 
patient  of  Dr.  De  Iloubaix.  It  was  hoped 
the  example  would  soon  be  followed  in 
Belgium ;  but  the  patient  died  from 
infiuences  almost  inseparable  from  a  large 
general  hospital.  This  unsuccessful  re- 
sult probably  retarded  for  a  time  the 
progress  of  ovariotomy  in  Belgium.  The 
first  successful  case  in  that  country  was 
by  a  pupil  of  my  own,  Dr.  Boddaert,  of 
Ghent.  I  had  a  successful  case  in  Ghent 
in  1871,  and  Dr.  Boddaert  had  2 
successful  cases  in  1872.  These  4 
cases,  I  am  informed,  Avere  the  only 
instances  of  success  out  of  about  20 
operations  in  that  country  up  to  that 
time.  Dr.  Boddaert  assures  me  that  it 
would  bo  impossible  to  obtain  accurate 
statistics  for  Belgium,  as  many  cases 
]emain  unpublished.  His  personal  ex- 
ficrience,  however,  to  the  end  of  1884 
amounts  to  21  cases  with  12  reco- 
veries  and  9   deaths  before  antiseptics; 


71  cases  since  antiseptics,  Avith  64  re- 
coveries and  only  7  deaths.  Besides  these, 
there  were  4  cases  of  cysts  of  the  broad 
ligament,  3  of  Avhich  recovered,  1  dying. 
This  makes  Dr.  Boddaert's  total  to  be  96 
cases,  79  recoveries  and  17  deaths. 

I  led  the  Avay  to  the  practice  of 
ovariotomy  in  Switzerland  by  operating 
at  Zurich  in  July  1864,  on  a  lady  Avho 
recovered  perfectly  Avell  and  has  enjoyed 
good  health  up  to  the  present  time.  Up 
to  1882  I  had  accounts  of  231  cases,  the 
recent  cases  having  been  treated  according 
to  Lister's  system.  The  results  Avere  177 
recoveries  and  54  deaths,  a  mortality  of 
23'3  per  cent.  One  of  the  fatal  cases 
was  most  deplorable,  as  shoAving  that,  in 
spite  of  the  most  exact  precautions,  the 
life  of  a  patient  and  the  reputation  of  an 
operator  are  at  the  mercy  of  thoughtless, 
if  not  culpable,  imprudence.  According 
to  custom,  the  sponges  Avere  coimted 
before,  and  Avere  counted  again  after,  the 
operation.  They  Avere  fixed  in  number, 
and  not  one  Avas  Avanting.  But  a  sponge 
Avas  left  in  the  abdomen,  and  the  sister 
accused  an  assistant  of  having  torn  a 
sponge  in  two  during  the  operation.  A 
similar  folly  was  just  stopped  in  time  here 
not  long  ago,  proving  that  the  sponges 
should  not  only  be  counted  but  iden- 
tified. 

In  Germany,  in  1819  and  1820  ope- 
rations by  Chrysmar,  and  in  1820  by 
Dzondi,  only  served  to  bring  the  opera- 
tion into  discredit.  Dieffenbach,  Avho 
had  long  condemned  the  operation,  ope- 
rated in  1826.  Martini,  Ritter,  and  others 
followed  Dieffenbach's  example,  but  Avith 
so  little  success  that  for  several  years 
the  operation  ceased  to  be  practised.  la 
1866  my  volume  on  *  Diseases  of  the 
Ovaries'  Avas  translated  into  German  by 
Kiicheumeister.  Billroth,  Avho  had  as- 
sisted me,  and  Avho  had  carefully  studied 
the  Avhole  subject,  began  to  use  his  great 
influence  Avith  his  countrymen  to  promote 
the  acceptance  of  the  operation.  Nuss- 
baum,  of  Munich,  came  twice  to  England, 
assisted  me  seA'eral  times,  and  has  per- 
formed ovariotomy  more  frequently  than 
any  other  German  surgeon  except  Schroe- 
der ;  and  Spiegelberg  entered  upon  ;% 
long  career  of  successful  operations. 
Grenser,  of  Dresden,  made  known  the 
results  of  a  long  visit  to  England  in  an 
able  review  of  what  he  saAv  here ;  and 
ovariotomy  is  now  generally  practised  in 
Germany  Avith  great  success. 


THE    RISE   AND   PROGRESS    OF   OVARIOTOMY 


Go 


Billroth,  writing  in  November  1H71, 
says :  '  Up  to  the  present  time,  I  am 
tolerably  contented  with  my  results.  I 
have  personally  no  reason  for  supposing 
that  the  results  will  be  less  cheering  in 
Vienna  than  they  are  in  London. 

Up  to  the  beginning  of  1877  01s- 
hausen  tabulated  613  cases  by  German 
operators  of  completed  ovariotomy,  with 
353  recoveries,  or  43  per  cent,  of  deaths 
and  57  per  cent,  of  recoveries. 

Recently  the  results  obtained  by 
Schroeder,  Nussbaum,  Olshausen,  Es- 
max'ch,  and  many  other  German  surgeons 
are,  to  say  the  least,  equal  to  those 
announced  in  any  other  country. 

Professor  Schroeder,  of  Berlin,  writing 
to  me  on  November  30,  1884,  says 
that  up  to  that  date  he  had  perlbrmed 
514  ovariotomies,  and  that  the  results  in 
successive  series  of  100  cases  were  as 
follows : 


1st  hundred  . 
2nd      „ 
3rd       „ 
4th       „ 
6th       „ 


SOO 


1 7  deaths 

18  „ 
7      „ 

16      „ 

7      „ 

65 


Mortality,  13  per  cent. 


Professor  Nussbaum,  of  Munich, 
writing  to  me  November  1884,  gives 
the  total  number  of  his  ovariotomies  as 
415.  Of  the  first  100,  37  died ;  of  the 
second  100,  26;  of  the  third,  16;  and  of 
the  last  115  cases  there  were  10  deaths. 
He  adds,  that  of  the  89  deaths,  44  were 
from  septicasmia.  His  youngest  patient 
was  17.  and  his  oldest  75.  This  old  lady 
recovered. 

Professor  Olshausen,  of  Halle,  writing 
on  December  26,  1884,  says  that  he  has 
performed  270  ovariotomies.  Of  these  28 
died.  Of  the  first  170,  24  died,  or  14-1 
per  cent.  Of  the  last  100,  only  4  died. 
Of  the  28  deaths,  13  were  from  septicaemia 
and  peritonitis,  6  shock,  2  exhaustion,  2 
pulmonary  embolism,  2  tetanus,  2  ob- 
structed intestines,  and  1  amyloid  kidneys. 
Six  of  the  operations  were  done  upon 
women  during  pregnancy,  and  all  the 
patients  recovered.  In  the  last  60  opera- 
tions the  pedicle  was  almost  always  secured 
by  elastic  ligature,  which  he  left  on  the 
pedicle. 

Professor  Billroth,  of  Vienna,  sends 
me  the  following  report  of  his  ovario- 
tomies from  1865  to  end  of  December 
1884: 


ki 

^^ 

Operations  arranged  in  serie? 

.2 

"S 

~  ? 

according  to  tlie  ditTlaulties 

s 

3 

S  o 

y< 

as 

I.  None  or  very  sli;;lit  adhe- 

sions of  omentum    . 

91 

9 

9-5 

II.  Extensive    adhesions     to 

anterior  abdominal  wall 

130 

33 

25-4 

III.  I'Lvtensivc  adhesions  deep 

in    the    pelvis,   or    with 

nicsenterv,         intestine, 

bladder,  uterus,  fee. 

95 

.53 

55-7 

IV.  Suppurating    or   putrefy- 

ing cysts — fever  i)atieiits 

8 

0 

77-7 

Total  number    . 

327 

101 

31-5 

Treatment  of  pedicle : 

1.  Extra-peritonea',         with 

clamp    .... 

79 

2h 

31-6 

2.  Intra-peritoneal 

248 

70 

oO-O 

Ovariotomies  before  the  use  of 

boiled  carboliscd  silk     . 

76 

31 

40  8 

Ovariotomies  after  the   us3  of 

carbolised  silk 

251 

70 

27-8 

Of  those  with  spray  . 

71 

29 

40-8 

,,        without  spray    . 

180 

41 

22-7 

Billroth,  writing  to  me  in  1881,  made 
the  following  interesting  remarks :  '  I 
must  explain  that  only  within  the  last  3 
years  have  I  begun,  in  cases  really  too 
difl[icult,  to  close  the  abdominal  incision 
and  leave  the  operation  incomplete.  Up 
till  3  years  ago  1  finished  at  any  cost  every 
operation  that  I  began,  and  this  naturally 
made  the  statistics  worse.  In  the  last  3 
years  I  have  closed  the  wound  in  12  cases, 
and  not  one  of  the  patients  has  died  in 
consequence  of  the  incision.  I  attach  very 
little  importance  to  figures  in  relation  to  a 
method  of  operating.  My  opinion  is  as 
follows.  Granted  that  the  operation  is 
well  done,  and  that  the  patient  does  not 
die  within  about  24  hours  from  loss  of 
blood  or  shock  (which  has  occurred  to 
me  only  4  times  in  2i!2  cases),  the  result 
depends  upon  whether  sponges,  fingers,  in- 
struments, secretions,  and  above  all  the 
ligature  threads,  are  clean.  If  this  be  so, 
all  get  well.  Three  weeks  ago  I  operated 
on  a  carcinoma  of  the  ovary  which  had 
grown  through  small  intestine  and  the 
bladder.  I  cut  away  8  centimetres  of  small 
intestine,  completed  the  enteroraphie  ;  then 
I  cut  away  the  upper  part  of  the  bladder 
and  united  it  with  20  sutures.  The  re- 
covery was  as  free  from  fever  as  in  the 
simplest  case,  and  the  patient  was  dis- 
charged cured  after  20  days.' 

In  the  north  of  Europe,  Dr.  Skoldberg, 
of  Stockholm,  deserves  the  credit  of  ]iro- 
mulgating,  by  his  example  and  writings, 
the  knowledge  of  the  operation  in  Sweden. 
Before  bis  death  in  1872,  he  had  performed 

F 


66 


OVARIAN   AND   ALLIED   TUMOURS 


30  operations,  with  a  result  of  26  recoveries 
and  4  deaths.  This  success  naturally  had 
a  great  influence  in  Sweden ;  and  Dr. 
Howitz,  of  Copenhagen,  and  Professor 
Nicolaysen,  of  Christiania,  who  both  as- 
sisted me  many  times,  have  done  good 
service  Avith  their  Danish  and  Norwegian 
countrymen.  Writing  December  26, 1884, 
ProfcFSor  Nicolaysen,  of  Christiania,  says 
that  he  has  done  109  ovariotomies,  about 
two-thirds  of  all  in  Norway,  which  alto- 
gether amount  to  166  cases,  with  61  deaths, 
a  mortality  of  36'7.  Of  Professor  Nico- 
laysen's  109  cases,  there  were  35  deaths. 
But  since  1878,  when  he  began  to  apply 
full  Listerism,  the  result  of  74  cases  has 
been  57  recoveries  and  17  deaths,  a  mor- 
tality of  23  per  cent. 

In  connection  with  the  practice  in 
Christiania,  Professor  Nicolaysen  makes 
remarks  to  this  effect :  That  the  great  mor- 
tality among  the  early  cases  was  princi- 
pally due  to  the  delay  in  seeking  relief  by 
operation,  as  most  of  the  patients  had  been 
subjected  to  long-continued  medical  treat- 
ment leading  only  to  anaimia,  adhesions, 
and  all  the  complications  of  old  cases. 
This  has  been  in  a  measure  changed  of 
late  years,  and  the  operations  have  taken 
place  at  an  earlier  stage  of  the  disease.  At 
the  same  time  antiseptic  precautions  have 
been  adopted,  the  carbolic  spray  and  dress- 
ing being  used.  Professor  Nicolaysen  adds 
that,  '  after  having  used  sulphurous  acid 
for  cleansing  the  sponges,  there  has  been 
a  remarkable  reduction  in  the  mortality.' 

In  Russia,  the  first  ovariotomy  was  per- 
formed at  CharkofF  by  Professor  Vanzetti 
in  1846,  and  the  second  at  Ilelsingtbrs 
in  1849,  by  Professor  Haartmann.  Both 
cases  were  unsuccessful.  The  first  suc- 
cessful case  was  performed  by  Professor 
Krassowski,  of  St.  Petersburg,  in  De- 
cember 1862,  and  his  results  were  after- 
wards so  satisfactory  that,  in  1868,  he  pub- 
lished the  well-known  atlas  of  beautifully 
coloured  plates.  His  example  has  been 
followed  by  many  Russian  surgeons.  In 
1882  there  had  been  302  ovariotomies  re- 
ported by  40  native  surgeons  in  St.  Peters- 
burg and  the  various  provinces  of  Russia. 
No  account  is  published  of  many  of  the 
ovarioiomies  done  in  Russia,  ami  the 
nu'iiber  is  really  much  greater.  All  but 
one  of  the  ovarian  cases  which  have  come 
to  me  from  Russia  recovered  from  the 
operation. 

In  Italy  the  first  successful  ovariotomy 
was  performed  by  Professor  Landi,  of  Pisa, 


in  September  1868  ;  the  second,  by  Pro- 
fessor Peruzzi,  of  Lugo,  in  1869  ;  the  third, 
by  Dr.  Marzolo,  of  Padua,  in  July  1871. 

Each  succeeding  year  brings  from  Italy 
news  of  greater  numbers  of  operations  and 
of  better  results. 

In  the  first  100  cases  performed  in 
Italy,  Peruzzi  proved  that  the  recoveries 
were  37  and  the  deaths  63,  while  in  the 
second  100  these  figures  were  rather 
more  than  reversed,  the  recoveries  being 
64  and  the  deaths  only  36.  In  the 
third  100  there  were  26  deaths,  in  the 
fourth  21 ;  but  in  the  fifth,  completed  in 
June  1884,  the  deaths  were  23 ;  and 
while  18  years  were  required  to  com- 
plete the  first  100  (1859-77),  the  fifth 
100  was  completed  in  13  months. 


It  has  sometimes  been  said  that  the 
first  ovariotomy  in  Europe  was  done  by 
Emiliani,  of  Faenza,  in  1815.  It  so  hap- 
pened that  the  tumour  he  removed  was 
preserved  in  the  mus'-um  at  Bologna,  and 
in  1878  I  arranged  with  Dr.  Peruzzi  that 
it  should  be  examined  by  Professor  Ranvier. 
Ranvier  wrote  with  extreme  caution,  but 
reported  that  in  all  his  sections  he  only 
observed  fibrous  tissue  without  any  trace 
of  glandular  structure. 

The  exact  size  and  form  of  this  tumour 


THE   RISE   AND   PROGRESS   OF  OVARIOTOMY 


67 


are  well  represented  in  tlio  woodcut  on 
the  previous  page. 

I  do  not  think  tliis  case  can  bo  cited 
as  a  case  of  ovariotomy  in  the  sense  in 
which  this  operation  has  been  regarded, 
from  its  first  performance  by  McDowell 
to  the  present  time.  Emiliani,  no  doubt, 
believed  he  had  removed  a  '  scirrhous 
ovary,'  and  it  is  certain  that  he  removed 
a  fil:)rou3  tumour  which  is  much  more 
like  a  uterine  than  an  ovarian  tumour. 
The  removal  of  such  a  tumoiir,  however, 
could  have  no  more  bearing  upon  the  rise 
of  ovariotomy  than  the  removal  of  a  hernial 
ovary  from  the  inguinal  canal. 

It  is  not  easy  to  obtain  information  as 
to  the  number  and  result  of  cases  of  ova- 
riotomy in  Spain  and  Portugal,  but  tliere 
is  reason  to  believe  that  they  are  neither 
so  numerous  nor  so  successful  as  in  Italy. 

In  India,  as  early  as  1860,  ovariotomy 
was  performed  successfully  at  Tan j ore 
by  a  native  surgeon.  In  Australia  many 
operators  have  emulated  their  English 
brethren.  In  New  Zealand,  Dr.  Mackin- 
non  was  the  pioneer  of  ovariotomy  at  our 
antipodes.  In  Canada,  the  few  cases  which 
have  been  published  have  been  almost  all 
successful ;  and  there  is  already  abundant 
evidence  that  ovariotomy  may  be  prac- 
tised successfully  under  the  most  different 
conditions  and  in  the  most  opposite  cli- 


mates.    One  case  was  reported  from  Japan 
in  1880. 

It  is  impossible  to  give  anything  like 
a  full  historical  sketch  of  the  progress 
of  ovariotomy  in  America  within  any  rea- 
sonable limits.  The  initiatory  work  of 
McDoAvell  has  been  already  described. 
Atlee  stood  next  to  myself  in  the  number 
of  operations  he  performed.  Kimball  of 
Lowell,  Peaslee,  Alarion  Sims,  Storer,  and 
many  other  American  surgeons  have  main- 
tained the  reputation  of  their  country  in 
this  department  of  surgery.  Works  by 
Atlee  and  Peaslee  were  published  in  1872, 
and  their  European  brethren  read  with 
great  interest  their  account  of  their  own 
work  and  that  of  their  countrymen. 

In  a  work  by  Agnew,  there  is  a  table 
compiled  by  Baum  of  5,153  cases  of  ova- 
riotomy, of  which  3,651  recovered  and 
1,502  died  =  29'13  mortality  per  cent. 
Of  these  there  were  : 


1  Mor     1 

Cases 

Ee- 
covered 

Died 

tality 
per 
cent. 

Single    .... 

4,9G9 

3,5.31 

1,438  1  28  94  | 

Double  .... 

183 

120 

63 

34-42 

During  pregnancy 

21 

17 

4 

19-05 

Twice     on    same 

patient    .     .     . 

15 

12 

3 

20-00 

But  this  table  includes  cases  both  of 
American  and  European  surgeons. 


CHAPTER   V 


THE    CONDITIONS   AFFECTING    THE  OPERATION    OF    OVARIOTOMT 


I  MAY  refer  students  interested  in  the 
statistics  of  ovarian  disease  in  England  to 
the  6th  chapter  of  my  work  published  in 
1882. 

The  cases  v^hich  come  under  the 
hands  of  the  surgeon  fall  into  two  groups  ; 
patients  who,  with  symptoms  calling  for 
immediate  action,  ought  to  be  given  the 
chance  of  a  preliminary  tapping;  and 
others  who  must  without  hesitation  be 
advised  to  submit  to  the  more  severe 
ordeal  of  ovariotomy. 

A  woman  with  a  single  unilocular  cyst 
may  suffer  to  such  a  degree  from  rapid 
accumulation  of  fluid  and  distension  that 
she  must  be  saved  by  some  means  from 
the  effect  of  mechanical  j^^i-ssure.  Once 
assured    that    the    cyst   really    is    single. 


tapping  may  be  tried ;  and  in  my  opinion 
it  should  be  enforced  by  almost  a  refusal 
to  do  ovariotomy  until  it  had  been  tested. 
But  this  advice  as  to  tapping,  and  espe- 
cially as  to  renewed  tapping,  as  a  means 
of  cure  must  be  restricted  absolutely,  as  I 
have  before  stated,  to  cases  in  Avhich  the 
cyst  is  single  and  the  contents  clear  and 
non-albuminous.  In  all  cases  of  multi- 
locular  cysts  or  dei-moid  tumours,  where 
the  abdominal  distension  is  sufficient  to 
injure  the  general  health  or  cause  local 
suffering,  there  must  be  no  faltering,  no 
suggestion  of  alternatives  or  delay.  Justice 
to  the  patient  demands  a  positive  recom- 
mendation of  excision,  and  generally  it 
should  be  accompanied  by  a  warning 
against  the   danger    of  delay.     Everyone 

F  2 


68 


OVARIAN  AND  ALLIED  TUMOURS 


■who  takes  upon  himself  the  responsibility 
o£  such  counsel  should  have  a  clear  id(-a 
©f  the  base  upon  which  it  rests.  And  it 
may  be  traced  out  summarily  in  this 
form.  The  health  has  already  deteriorated, 
and  though  the  tumour  itself  be  neither 
malignant,  nor  inflamed,  nor  suppurating, 
nor  the  seat  of  haemorrhage,  yet  its  mere 
presence  is  the  cause  of  the  patient's 
decline.  To  let  things  go  from  bad  to 
worse  without  doing  anything,  especially 
as  that  worse  is  a  certainty,  would 
be  acting  again^t  the  very  first  principles 
of  medical  science.  The  presence  of  this 
morbid  growth  in  the  body  may  give 
rise  to  other  diseases.  It  attaches  itself 
oftentimes  to  the  intestines,  mechanically 
blocks  the  passage  through  them,  or 
causes  fatal  contractions,  and,  at  the  very 
least,  impairs  their  functions  and  hinders 
the  due  assimilation  of  food.  Its  con- 
tinuance allows  time  for  the  balance  of 
the  action  of  the  heart  and  lungs  to  be 
deranged,  and  for  structural  changes  to 
take  place,  which  if  not  immediately  fatal 
or  sufficient  to  mar  the  operation,  may 
render  recovery  of  health  after  ovario- 
tomy slow  or  incomplete. 

As  time  advances,  the  natural  tendency 
of  the  tumour  to  degenerative  changes 
finds  scope  for  progress.  Whatever  its 
tissues  may  be,  they  are  never  lastingly 
normal,  have  a  precarious  parasitic  exist- 
ence, gain  their  supply  of  blood  as  it  were 
surreptitiously,  and  are  easily  thrown 
into  the  condition  of  atrophic  decay.  The 
expansion  of  the  membranous  compart- 
ments obliterates  the  vessels,  fatty  and 
other  changes  occur,  and  rupture  is  always 
imminent.  The  contents  too,  whatever 
they  may  have  been  at  first,  alter  in  their 
character  and  become  less  and  less  benign. 
And  by  too  long  waiting,  sympathetic 
morbid  action  may  be  set  up  in  the  cor- 
responding organ,  and  thus  make  the 
ablation  of  both  imperative. 

Time,  too,  gives  the  opportunity  for 
adhesions  to  form,  for  rupture  or  de- 
structive peritonitis  to  occur.  With  some 
tumours  growing  on  a  long  pedicle  twist- 
ing may  cause  haemorrhage  or  gangrene 
The  contingency  of  conception  and  preg- 
nancy is  an  avoidable  complication.  Still 
it  is  no  less  to  be  thought  of  and  made  the 
subject  of  warning. 

Jn  many  cases  ovariotomy  may  be  per- 
formed with  a  confident  hope  of  a  success- 
ful result;  in  others  the  probabilities  of 
auccess  or  failure  may    be   about  equal, 


while  in  some  the  hope  of  success  is  so 
small,  that  most  patients,  who  are  told  the 
whole  truth,  prefer  waiting  for  the  natu- 
ral termination  of  the  disease  to  volun- 
tarily placing  their  lives  in  immediate 
peril.  Some,  however,  would  urge  the 
unwilling  surgeon  to  operate  against  his 
better  judgment,  and  I  have  often  yielded 
to  the  solicitations  of  patients  who,  their 
sufferings  being  great  and  death  being  in- 
evitable at  no  distant  period,  have  pre- 
ferred running  any  risk  rather  than  submit 
to  a  continuation  of  suffering.  In  only 
one  case  have  I  refused  to  operate  when 
pressed  to  do  so  by  a  patient  capable  of 
appreciating  the  difficulties  of  the  position. 
In  this  case,  a  woman  in  the  Samaritan 
Hospital  suffered,  as  I  believed,  from 
malignant  disease,  involving  the  uterus 
and  both  ovaries,  and  had  a  large 
quantity  of  fluid  free  in  the  peritoneal 
cavity.  I  removed  this  fluid,  but  refused 
to  do  more,  although  the  woman  threat- 
ened to  commit  suicide  if  I  did  not  operate. 
After  her  death,  the  correctness  of  the 
diagnosis  was  fully  borne  out.  I  have 
heard  of  some  few  cases  where  patients 
whom  I  had  dissuaded  from  the  operation 
have  been  encouraged  by  others  to  submit 
to  it;  and,  with  one  exception,  every  such 
patient  has  died  after  the  operation.  The 
exceptional  case  was  a  woman  who  had 
been  several  times  tapped,  and  who  had 
been  advised  both  by  Dr.  Keith  and  by 
me  not  to  think  of  ovariotomy  so  long  as 
life  could  be  made  tolei-able  by  tappings. 
Fifteen  months  after  I  saw  her,  the  tumour 
was  removed  by  Dr.  Graham,  of  Liver- 
pool, Avho  encountered  and  overcame  the 
pelvic  and  other  adhesions  which  both  Dr. 
Keith  and  I  had  recognised,  and  obtained 
the  satisfaction  of  saving  a  life  otherwise 
inevitably  lost.  I  have  thought  it  neces- 
sary to  make  this  statement  distinctly, 
because  it  has  been  supposed  that  ova- 
riotomy has  been  restricted  to  favourable 
cases  only,  and  that  good  results  had  been 
obtained  by  refusing  to  operate  upon  any 
but  selected  cases.  Indeed,  this  was 
known  to  be  the  case  in  the  early  days  of 
ovariotomy  in  this  country. 

Before  going  into  the  numerical  exa- 
mination of  the  question  as  to  how  far  the 
age  and  condition  of  the  patient,  the  size 
of  the  tumour,  the  existence  of  adhesions, 
the  length  of  the  pedicle,  have  affected 
the  result  in  my  whole  practice,  I  think 
we  may  conclude  that  this  experience 
has  now    been    sufficient    to  warrant  the 


CONDITIONS  AFFECTING   THE   OPEEATION   OF   OVARIOTOMY       69 


acceptance    of    some    such    rule    as    tlie 
following : 

The  probable  result  of  ovariotomy  can 
be  estimated  with  far  greater  accuracy  by 
a  knowledge  of  the  general  condition  of  the 
patient  than  by  the  size  and  condition  of 
the  tumour. 

In  other  words,  a  large  tumour,  exten- 
sively adherent,  in  a  patient  whose  heart 
and  lungs,  and  digestive  and  eliminative 
organs,  are  healthy,  and  whose  mind  is 
well  regulated,  may  be  removed  with  a 
far  greater  probability  of  success  than  a 
small  unattached  cyst  from  a  patient  who 
is  anoemic  or  leuka^mic.  whose  heart  is 
feeble,  whose  assimilation  and  elimination 
are  imperfect,  or  whose  mind  is  too  readily 
acted  upon  by  either  exciting  or  depress- 
ing causes.  I  believe  this  to  be  the  ex- 
planation of  the  facts  which  have  led  some 
superficial  observers  to  assert  that  the 
more  advanced  the  disease  the  greater,  and 
the  earlier  the  stage  of  the  disease  the 
less,  is  the  probability  of  recoverj'.  I  am 
convinced  that  this  reasoning  is  based  on 
the  observation  of  a  few  exceptional  cases 
where  small  unattached  tumours  have  been 
removed  with  a  fatal  result  i'rom  unhealthy 
or  infected  persons;  or  where  large 
attached  tumours  have  been  successfully 
removed  from  persons  who  have  otherwise 
been  constitutionally  sound.  Small  un- 
attached tumours  in  sti'ong  healthy  persons 
have  by  no  means  given  the  best  results. 
It  is  possible  to  operate  too  early  as  well 
as  too  late — to  place  a  patient's  life  in 
peril  by  operation  before  it  is  endangered 
by  the  disease  ;  just  as  it  is  possible,  on 
the  other  hand,  to  delay  operation  until 
the  powers  of  life  are  so  exhausted  that 
recovery  after  a  severe  operation  is  im- 
possible. A  strong  man  in  full  health, 
with  a  limb  crushed  by  a  railway  accident 
or  shattered  by  a  bullet,  bears  amputation 
worse  than  another  man  who,  on  account 
of  diseased  knee-joint,  has  been  confined 
to  his  room  lor  weeks  or  months.  So  a 
woman  who  has  become  accustomed  to 
the  confinement  of  a  sick-room,  has  lost 
flesh,  and  has  been  brought  by  her  suf- 
fering to  dread  the  operation  less  than 
the  disease,  bears  the  removal  of  an 
ovarian  tumour,  even  though  large  and 
adherent,  better  than  one  whose  whole 
course  of  life  is  suddenly  changed  from 
the  performance  of  ordinary  active 
duties  to  the  enforced  quiet  and  con- 
finement in  bed  which  necessarily  follow 
ovariotomy. 


SIZE 

The  size  of  an  ovarian  tumour  has 
not,  by  itself,  appeared  to  affect  the 
result ;  but  size  and  solidity  together, 
by  affecting  the  length  of  the  incision 
necessary  for  the  removal,  appear  to  be 
of  some  importance.  If  there  be  but 
little  solid  or  semi-solid  substance  present 
— which  is  generally  easily  discovered 
belbre  operation — large  adherent  cysts 
holding  50,  CO,  or  70  pounds  of  fluid 
may  be  removed,  after  the  contents  of 
the  cyst  have  been  evacuated,  through 
an  opening  only  just  large  enough  to 
admit  one  of  the  operator's  hands.  The 
result  of  such  cases  has  been  satisfactory; 
but  the  mortality  has  been  greater  when, 
longer  incisions  have  been  necessary. 
The  number  of  inches  is  a  very  imperfect 
mode  of  judging  of  the  length  of  incision. 
In  a  small  woman  with  a  tumour  of 
moderate  size,  an  incision  of  8  or  10 
inches  would  extend  almost  from  sternum, 
to  pubes ;  while  in  a  large  woman, 
greatly  distended  by  a  large  cyst,  an 
incision  of  this  length  may  be  made 
below  the  umbilicus,  and  after  the  con- 
traction of  the  abdominal  wall,  the  cica- 
trix may  not  be  more  than  3  or  4 
inches  long.  In  examining  a  case  for 
operation,  it  becomes  important  to  judge 
whether  a  cyst  or  tumour  can  be  removed 
by  an  incision  which  does  not  extend 
above  the  umbilicus.  If  this  can  be 
done,  the  probability  of  success  is  much 
greater  than  when  it  becomes  necessary 
to  extend  the  incision  far  above  the 
umbilicus. 

ADHESIONS 

Writing  in  1872,  I  reported  that  in 
296  cases  out  of  the  first  500  there  were 
no  adhesions,  or  they  were  so  slight  as 
to  be  almost  unnoticed.  Of  these  patients 
237  recovered  and  59  died,  the  mortality 
being  19'93  per  cent.  In  204  cases, 
adhesions  were  very  extensive  :  of  these 
patients  136  recovered  and  68  died — a 
mortality  of  33-33  per  cent.  This 
would  show  that  the  mortality  of  cases 
where  there  are  considerable  adhesions  is 
about  13  per  cent,  greater  than  in  cases 
where  there  are  no,  or  only  trifling,  ad- 
hesions. But  a  more  careful  examina- 
tion of  each  case  appears  to  confirm  the 
conclusion  at  which  1  arrived  some  years 
ago,  that  adhesions  to  the  abdominal  wall, 
or  omentum  only,  have  but  little  influence 


70 


OVARIAN   AND   ALLIED   TUJMOURS 


upon  the  mortality,  and  that  the  import- 
ance   which   has   been    attached   to   the 
diagnosis  of   adhesions   before    operation 
has  been  greatly  and  unnecessarily  ex- 
aggerated.     At  the    same  time  the  dia- 
gnosis of  adhesions  within  the  pelvis  is  of 
very  great  importance,  as  the  attachments 
to  the  bladder  or  rectum   may  be  almost 
inseparable  withoiit  great  and  immediate 
danger  to  life.     The  same  may  be  said  of 
attachments  to  the  liver,  stomach,  spleen, 
or  around  the  brim  of   the   pelvis,    the 
separation  of  which  would  endanger  the 
iliac  vessels  or  the  ureters.     I  formerly 
believed    that  the  closeness  of  the  con- 
nection    between    the    uterus    and    the 
ovarian     tumour — in    other    words,    the 
length     of     the    pedicle — was    a    grave 
matter,  as  upon  its  extent  depended  the 
possibility   of    keeping    the    end   of  the 
secured    pedicle    outside  the    peritoneal 
cavity,    or   the    necessity  for   leaving  it 
within  this  cavity.     But  during  the  last 
5    years,    having    quite     abandoned    the 
extra-peritoneal  treatment  of  the  pedicle, 
a   short  pedicle,  or  close  connection  be- 
tween cyst  and  uterus,  becomes  important 
in  leading  to  greater  difficulty  in  securing 
bleeding  vessels.     But  it  also  leads  to  the 
advisability     of    uniting     the    peritoneal 
edges  of  the  divided  pedicle,  or  separated 
tumour,    by    suture,    in    order    to    avoid 
dangers  Avhich  will  be  pointed  out  in  the 
chapter  on  the  operation.      Some  of  these 
remarks,  written  in  1872,  were  intended  to 
convey  the  result  of  an  impression  made 
by  a  general  survey  of  the  1st  500  cases 
reported,  and  by  reminiscences  of  what 
happened  at  and  after  the  operations.   But 
the    information    obtained   from    a  more 
exact  investigation  of  the  2nd  500  cases, 
and  embodied  in  the  accompanying  table, 
does  not  correspond  with  that  impression: 

Table  showing  tiik  Effect  of  Adhesions 
UPON  THE  Kksi  i/rs  OF  Operations  in  the 
'2nd  iiOO  Cases  of  Ovauiotomy 


'£ 

&-.^. 

•g 

2 

2  c 

Adhesions 

> 

"Xl 

3  u 

« 

o 

ts 

"-  u 

o 

1) 

o  S 

M 

O 

l^ft 

None         .... 

212 

18.3 

29 

1.3-07 

Parietal    .... 

(Jl 

.')() 

11 

18 

Parietal  aa^l  omental 

0.3 

ol 

12 

19 

Omental   .... 

C2 

47 

]^) 

24-19 

Intestinal,  pelvic  &  otliers 

102 

04 

38 

37-25 

500   395 

105 

21 

The  general  mortality  after  the  opera- 
tion is  seen  to  have  been  reduced  Irom 


25"4  to  21  per  cent. ;  while  the  large 
increase  in  the  mortality  among  the  bad 
cases  of  visceral  adhesion  is  noticeable. 
This  may  be  accounted  for  by  the  greater 
boldness  with  which  excisions  were  latterly 
undertaken  and  carried  to  completion. 
Many  of  the  later  operations  finished, 
would  formerly  have  been  refused  as 
hopeless,  or  abandoned  after  the  first  inci- 
sion, and  added  to  the  tables  of  in- 
complete cases  or  exploratory  incisions. 
But  with  regard  to  what  have  been 
spoken  of  as  '  slight '  adhesions — that  is, 
adhesions  to  the  parietes  and  to  the 
fringes  of  the  omentum — the  table  pre- 
sents us  with  a  mortality  of  5  per  cent, 
in  excess  of  that  of  the  simple  cases ; 
while  the  deaths  after  separation  of 
omental  adhesions  are  double,  or  nearly 
so,  those  among  the  free  cyst  operations, 
the  relative  percentages  being  13-()7 
for  the  non-adhesions  and  24-19  for  the 
omental  adhesions. 

Now,  when  we  take  into  account  that, 
according  to  my  experience,  nearly  three- 
fifths  of  the  cases  operated  on  have  adhe- 
sions of  some  kind,  and  that  the  mortality 
of    the   group    of    adhesion   cases,    as   a 
whole,    was   double   that   of  the    simple 
cases — 2G-o8  to  13"67- — it  gives  a  serious 
aspect  to  the  general  question  of  adhesions. 
The  death-rate  of  37 '25  in  bad  cases   of 
visceral  adhesion,  found  in  one-fifth  of  the 
total  number,  at  a  time  when  the  general 
mortality  after  my  operations  was  rapidly 
coming  down  to  10  per  cent.,  speaks  for 
itself  as  to  the  gravity  of  the  prognosis  in 
such  cases.     And  the  other  fact  shown  by 
this    investigation  of  my   2nd  500  cases, 
that  even  with  the  so-called  trifling  adhe- 
sions— that  is,  cases  in  which  the  adhesions 
were  only  parietal  or  partially  omental — 
the  deaths   were    nearly    one-half    more 
(18'54)  than  in  the  free  cyst  cases,  and 
that  among  the  adhesions  classed  as  omental 
the  mortality  was  nearly  double  (24-19), 
corrects  the  impression  that  adhesions  of 
this  kind  wore  not  of  much  importance. 
Their  existence  should  not  deter  from  the 
operation,  nor  make  anyone  falter.     But 
these  facts  mark  more  strongly  than  ever 
the  importance  of  avoiding  everything  in 
the  early  stages  of  the  disease  which  may 
produce  adhesions,  of  not  letting  the  time 
for  operating  go  by  when  the  cyst  is  free, 
and  of  giving   a  proportionally  guarded 
prognosis   as   to    the   probable   result   of 
operation   when  extensive  adhesions  are 
known  to  be  present. 


CONDITIONS  AFFECTING  THE   OPERATION  OF   OVARIOTOMY      71 


AGE 

The  average  age  of  1,000  cases  of 
completed  ovariotomy  proves  to  be  as 
near  as  possible  39  years. 

The  small  mortality  shown  in  my 
reports  of  operations  upon  persons  under 
the  age  of  25  and  between  60  and  70  is 
remarkable  when  compared  Avith  that  of 
the  intermediate  ages — 40  to  45  excepted. 
The  127  young  people  under  25  years  of 
age  went  through  the  operation  with  a 
mortality  of  12-59  per  cent. ;  the  45 
between  60  and  70  escaped  with  a  loss 
of  1 7*77  per  cent.;  while  those  between 
25  and  60  died  at  the  rate  of  26-41  per 
cent.  From  these  I  omit  118  of  from  40  to 
45,  who  were  fortunate  enough  to  have  a 
death-rate  of  only  16'94  per  cent.  One 
■of  the  two  cases  over  70  died.  I  have 
not  been  able  to  make  out  what  were  the 
influences  acting  so  favourably  upon  the 
40-45  cases.  That  it  was  not  a  mere 
iiccident  would  appear  from  the  fact  that 
the  immunity  at  that  age  was  not  confined 
to  any  part  of  the  series,  but  was  about 
equal  in  the  two  five  hundreds. 

MORTALITY    AT    DIFFERENT    AGES 

In  reference  to  this  subject  Dr.  Ogle 
wrote  to  me  thus :  *  Among  the  3,414 
deaths  ascribed  in  the  10  years,  1871-80, 
either  to  ovarian  dropsy  or  to  ovariotomy, 
were  2  of  girls  under  15  years  of  age, 
and  7  of  women  over  85  years  of  age. 
The  greatest  absolute  number  occurred 
between  the  ages  of  45  and  55,  and  next 
to  this  came  the  decennia  on  either  side 
of  this  period  of  life.'  But  taking  into 
account  the  different  numbers  of  women 
living  at  each  period,  Dr.  Ogle  adds  :  '  It 
appears  that  the  time  of  life  when  this 
disease  is  most  fatal — that  is,  causes  most 
deaths  in  proportion  to  the  number  living 
— is  from  55  to  65,  and  the  next  fatal 
periods  are  the  decennia  on  either  side  of 
this.' 

CONJUGAL    CONDITION 

The  mortality  was  nearly  equal  among 
married  and  unmarried  women  at  all  ages, 
in  1,000  patients. 

SOCIAL    CONDITION 

The  results  of  operations  in  hosjoital 
and  private  practice  are  affected  by  many 
other  causes  besides  the  social  condition 
of  the  patients. 

Under  favourable  circumstances  the 
rate  of  death  has  been  so   nearly  equal 


in  all  classes  of  patients  that  it  overturns 

the  belief  formerly  entertained  by  some 
writers,  that  deaths  have  been  chiefly 
among  poor  women,  and  that  this  is  not 
accidental.  My  experience  certainly 
does  not  support  the  conclusion  that  '  the 
social  position  of  the  patient  has  a  good 
deal  to  do  with  the  result.'  My  hospital 
patients  were  poor,  though  lew  could 
actually  be  ranked  as  paupers. 

Many  of  the  private  operations  have 
been  performed  in  the  houses  now  common 
in  London,  where  it  is  intended  that  a 
patient  shall  obtain  the  conjoint  advan- 
tages of  an  hospital  and  of  home  or 
private  apartments.  There  can  be  no 
doubt  of  the  advantages  of  such  houses, 
provided  the  management  is  good.  But 
they  must  always  be  open  to  the  objection 
of  subjecting  one  patient,  more  or  less, 
to  the  influence  of  others  in  adjoining 
rooms  or  in  the  same  house.  I  am  con- 
vinced that  some  of  the  deaths,  both  in 
hospital  and  in  the  nursing  establish- 
ments, have  been  due  to  the  injurious 
influence  of  other  patients  upon  the  sub- 
ject of  the  operation;  an  influence  which 
would  not  have  been  felt  in  a  private 
house.  Apart  from  all  question  of  in- 
fection, my  belief  is  that,  in  the  one 
case,  if  any  important  peritonitis  follow 
the  operation,  the  inflammation  is  almost 
always  local,  not  attended  by  much 
effusion  of  serum,  nor  by  elevation  of 
temperature  or  other  signs  of  fever  or 
blood-poisoning ;  Avhei'eas,  under  the 
influence  of  other  patients  in  the  same 
house  the  inflammation  is  diffused,  is  ac- 
companied by  the  rapid  effusion  of  a  con- 
siderable amount  of  fluid,  Avith  great 
elevation  of  temperature  and  other  indi- 
cations of  septicajmia.  I  am  becoming 
more  and  more  doubtfuh  if  we  ever  see 
this  latter  chain  of  symptoms,  either  in 
hospital  or  in  healthy  houses,  if  the 
patients  are  kept  quite  free  from  the 
access,  by  contagion  or  infection,  of  the 
poisonous  material — solid,  liquid,  or  gase- 
ous— which  acts  as  certainly  as  an  inocu- 
lated particle  of  small-pox  or  vaccine 
virus,  or  as  the  inspiration  of  an  infective 
atmosphere  in  scarlatina,  and  from  which 
the  patient  is  absolutely  safe  in  the 
absence  of  the  poison. 

INFLUENCE    OF    SEASON 

The  general  result  of  my  experience 
is  that  seasons,  as  expressed  by  winter, 
spring,  summer,  or  autunm — or  that  hot 


iZ 


OVARIAN   AND   ALLIED   TUMOURS 


or  cold  months,  or  any  particular  month — 
have  little  or  no  influence  upon  the  result 
of  ovariotomy;  and  with  regard  to  any 
exceptional  atmospheric  or  climatic  con- 
ditions, all  we  can  say  is  that  this  is  a 
case  for  '  Collective  Investigation,'  that 
the  combined  action  of  many  observers 
in  every  variety  of  social,  territorial, 
climatic,  and  professional  conditions,  ex- 
tending over  adequate  time  and  numbers, 
must  be  brought  to  bear  upon  the  sub- 
ject before  we  can  formulate  the  laws 
which  determine  the  results  of  season 
upon  our  operations. 

CONTRA-  INDICATIONS 

As  a  general  rule,  any  existing  disease 
which  in  its  natural  course  would  prove 
fatal  to  the  patient,  or  would  influence 
her  constitution  in  such  a  manner  as  to 
render  her  recovery  very  unlikely,  or 
other  serious  surgical  operations  inad- 
missible, should  also  forbid  ovariotomy. 
It  ought  not  to  be  resorted  to  in  indi- 
vidvials  suffering  from  cancer,  far-ad- 
A-anced  tubercizlosis  or  scrofula,  syphilis, 
important  diseases  of  the  heart,  or  in 
cases  where  this  organ  has  been  displaced 
by  the  tumour,  and  at  the  same  time  has 
been  fixed  in  its  abnormal  site  by  ad- 
hesions which  would  retain  it  in  its 
position  even  after  the  removal  of  the 
ovary  ;  diseases  of  the  brain  and  of  the 
nervous  centres,  of  the  liver,  spleen,  and 
kidneys ;  ulcers  of  the  stomach  and 
diseases  of  the  alimentary  canal,  which 
permanently  impair  general  nutrition  ; 
ascites  in  consequence  of  liver  complaint, 
of  disease  of  the  heart,  or  degeneration 
of  the  kidneys.  The  mere  presence  of 
albumen  in  the  urine  has  often  had  undue 
weight.  It  is  often  of  no  more  impor- 
tance than  in  pregnancy,  and  disappears 
after  the  pressure  of  the  tumour  ceases. 
Scurvy,  anaemia,  and  other  blood  diseases, 
hectic  lever,  great  w^eakness  and  extreme 
emaciation  from  advanced  age  or  im- 
paired nutrition,  would  lead,  if  not  to 
absolute  prohibition,  to  a  very  un- 
favourable opinion  as  to  the  probable 
result. 

But  scarcely  ever  will  the  judgment 
of  the  surgeon  be  so  severely  tested  as  in 
estimating  the   value  and   importance  of 


many  of  the  above-mentioned  contra- 
indications, whether  any  one  is  by  itself 
so  serious  as  to  preclude  surgical  inter- 
ference, or  is  merely  a  consequence  of 
the  local  disease.  This  may  be  instanced 
by  one  of  my  cases  where  all  the  sym- 
ptoms of  far-advanced  tuberculosis  were 
present — cough,  hectic  fever,  high  tem- 
perature, and  rapid  pulse- — -which  all  dis- 
appeared after  extirpation  of  the  ovarian 
tumour.  The  pulse  fell  from  108  to  88,. 
the  temperature  from  lOl'-i"  F.  to  its 
normal  range;  cough  was  no  longer 
troublesome.  It  may  be  added  that  the 
cyst  contained  genuine  tubercular  de- 
posits, was  thin-walled,  and  very  fragile. 

The  operation  ought  not  to  be  per- 
formed when  the  tumour  is  in  an  ad- 
vanced stage  of  cancerous  degeneration. 
But  so  many  instances  of  recovery  after 
extirpation  of  what  was  pronounced  to  be 
cancer  are  well  known,  that  there  must 
be  more  than  bare  suspicion  to  set  aside 
the  operation.  Cancer  of  the  ovaries  is- 
supposed  to  occur  most  frequently  after 
the  change  of  life ;  but  cases  have  been 
mentioned,  in  another  chapter,  of  this 
disease  in  a  young  girl,  and  in  middle- 
aged  women.  Such  tumours  often  form 
extensive  and  intimate  adhesions,  taint 
the  surrounding  tissues,  and  attack  the 
neighbouring  organs,  with  which  they 
form  at  an  advanced  stage  of  the  degene- 
ration one  confluent  mass.  In  most  cases, 
their  extirpation,  if  attempted,  would 
meet  with  insurmountable  difficulties ; 
and  should  the  operation  be  terminated 
and  the  patient  recover  from  it,  the 
disease  would  sooner  or  later  attack  some 
other  part  or  organ.  Ascites  generally 
accompanies  malignant  disease  of  the 
ovaries,  and  both  ovaries  are  usually 
affected  at  the  same  time. 

The  presence  of  ascites  need  not 
deter  from  the  operation,  provided  it  be 
due  to  escape  of  fluid  from  the  cyst,  or  is- 
brought  on  by  the  mechanical  irritation 
of  the  peritoneum  by  the  tumour.  If, 
however,  it  is  caused  by  disease  of  heart, 
liver,  or  kidneys,  these  conditions  almost 
always  forbid  the  operation.  The  compli- 
cation of  pregnancy  with  ovarian  disease, 
and  its  be  aring  on  ovariotomy,  are  treated 
of  in  a  subsequent  chapter. 


CHAPTER  VI 


PREPARATION    OF 


A    PATIENT    FOR    OVARIOTOMY  ;     DUTIES    OF    THE    NURSE  ;     DESCRIPTION 
OF    NECESSARY    INSTRUMENTS 


It  by  no  means  follows  that  the  state  of 
robust  health  is  one  so  favourable  for 
operation  as  that  of  a  patient  more  or 
less  accustomed  to  the  quiet  and  habits  of 
a  sick-room.  And  it  is  perhaps  one  of 
the  most  difficult  questions  which  the 
surgeon  has  to  determine,  whether  a 
patient  not  yet  broken  down  by  the  pro- 
gress of  the  disease,  is  suffering  enough 
in  general  condition  to  warrant  him  in 
recommending  an  operation  necessarily 
attended  with  serious  risk  to  life.  Every 
case  must  be  judged  by  its  own  pecu- 
liarities ;  not  those  only  which  relate  to 
the  physical  condition  of  the  patient,  but 
the  various  moi-al,  mental,  and  social 
influences  which  have  so  constantly  to  be 
considered  in  daily  practice,  and  which  so 
materially  affect  the  results  of  any  opera- 
tion. For  instance,  an  unmarried  girl 
with  ovarian  disease  is  often  so  distressed 
by  the  suspicions  which  her  appearance 
excites,  that  she  must  be  relieved  earlier 
than  a  married  woman  of  the  same  size 
needs  be ;  and  a  girl  engaged  to  be 
married,  and  naturally  unwilling  to  marry 
as  an  invalid,  may  claim  with  good  reason 
earlier  aid  from  surgery  than  one  not  so 
pledged.  The  same  would  hold  good 
with  a  wife  wishing  to  travel  with  her 
Imsband,  or  to  join  him  in  some  distant 
part  of  the  world.  On  the  other  hand, 
there  are  iarnily  circumstances  which 
would  properly  delay  opeiation  till  the 
last  possible  moment.  Children  may  be 
dependent  on  the  annuity  of  the  mother, 
whose  life  should  not  be  subject  to  the 
additional  risk  of  the  operation  until  it  is 
imperatively  called  for  by  the  severity  of 
her  sufferings.  In  many  cases  such  con- 
siderations have  guided  me  in  operating 
either  eaidier  or  later  than  one  would  do 
if  only  obliged  to  regard  what  was  best 
for  the  bodily  welfare,  and  able  altogether 
to  ignore  the  affections,  interests,  and  cir- 
cumstances of  patients. 

A  condition  which  certainly  requires 
correction  before  the  operation  is  under- 
taken, is  that  common  one  where  only  a 
small  quantity  o£  highly  concentrated 
urine,  depositing  mixed  urates  in  abund- 
ance, is  passed.     If  ovariotomy  be  per- 


formed on  a  patient  in  this  condition,  a 
serious  amount  of  kidney  congestion,  with 
symptoms  almost  amounting  to  urasmic 
fever,  is  almost  certain  to  follow  the- 
operation.  Before  undertaking  it,  there- 
fore, it  may  be  necessary  to  gain  time  by 
tapping.  Whether  or  no  this  may  be 
necessary,  warm  baths  or  vapour  baths, 
to  promote  free  cutaneous  secretion,  some- 
thing to  secure  a  free  daily  action  of  the 
bowels,  and  some  of  the  alkaline  car- 
bonates, largely  diluted,  will  most  likely 
greatly  improve  the  condition  of  the 
patient.  Nothing  tends  so  rapidly  to- 
clear  the  urine  as  lithia.  From  5  to  10 
grains  of  the  citrate  or  carbonate  of  lithia, 
dissolved  in  a  full  proportion  of  simple 
or  aerated  water,  2  or  3  times  a  day, 
generally  lead  to  a  moi'e  abundant  secre- 
tion of  urine  which  is  free  from  deposit. 
Sometimes  it  is  a  good  plan  to  combine 
the  carbonates  of  lithia,  potash,  and  soda^ 
and  it  may  be  desirable  to  give  iron  at 
the  same  time.  A  draught  of  5  grains 
of  tartrate  of  iron,  5  of  carbonate  of 
lithia,  and  10  each  of  the  bicarbonates 
of  potash  and  soda,  Avith  a  few  drops  of 
chloric  ether,  2  or  3  times  a  day,  has 
has  often  appeared  to  me  to  be  of  great 
service.  A  course  of  perchloride  of  iron 
before  any  serious  surgical  operation  is 
said  so  to  alter  the  condition  of  the  blood  as 
to  make  pyemic  fever  or  septicaamia  less 
liable  to  occur.  A  change  to  the  seaside 
or  country  will  assist  the  restorative  action 
of  medicines  ;  and  if  the  patient  is  brought 
from  the  country  it  may  be  well  to  ar- 
range for  the  performance  of  the  opera- 
tion before  the  influences  of  town  life  have 
had  time  to  prove  injurious. 

The  place  where  the  operation  is  per- 
formed ought  to  be  healthy,  and  there  can 
be  no  excuse  for  putting  or  leaving  the 
patient  in  an  unhealthy  house  or  district. 
If  she  lives  in  a  healthy  part  of  the 
country  and  can  be  treated  there,  it  would 
be  positive  cruelty  to  bring  her  to  an 
unhealthy  part  of  town,  or  to  expose  her 
to  the  influences  of  a  lar";e  general 
hospital.  Even  in  the  same  town,  or  in 
the  same  district  of  large  cities,  better 
results   have    been   obtained    in   private 


74 


OVAKIAN  AND   ALLIED  TUMOURS 


houses  and  in  small  hospitals,  where  the 
patient  occupies  a  room  alone,  than  in 
large  general  hospitals.  It  is  well  worthy 
of  remark  that  the  periods  of  good  and 
indifferent  results  in  the  Samaritan  Hos- 
pital have  corresponded  with  improve- 
ments in  its  sanitary  condition.  After 
emptying  the  hospital  for  a  month  or 
more,  and  thoroughly  cleansing,  painting, 
and  lime-washing  the  wards,  a  period  of 
almost  uninterrupted  success  has  followed. 
Then  what  was  called  'a  run  o£  bad  luck  ' 
set  in,  clearly  attributable  to  crowding, 
some  neglect  in  purifying  bedding,  or  to 
contagion  or  infection.  Another  thorough 
cleansing  again  led  to  better  results.  If 
we  could  obtain  all  the  favourable  con- 
ditions of  a  room  in  a  private  house,  in  a 
healthy  country  situation,  there  can  be 
no  doubt  that  the  mortality  would  be 
much  smaller  than  the  best  results  hither- 
to attained  in  large  towns. 

The  ward  or  room,  whether  in  a  small 
hospital  or  in  a  private  house,  should  be 
well  provided  with  means  for  keeping  up 
a  continual  and  sufficient  ventilation, 
without  exposing  the  patient  to  currents 
of  cold  air,  and  the  temperature  should 
be  regulated  by  an  open  lire.  In  a  build- 
ing constructed  lor  tlie  purpose,  it  would 
seem  to  be  easy  to  keej:)  up  a  constant 
curi-ent  of  fresh  air,  at  any  temperature 
required,  night  and  day;  but  what  is 
theoretically  easy  in  warming  and  ven- 
tilating has  probably  never  yet  been  done 
well.  All  unnecessary  furniture  should 
be  removed  irom  the  room,  particularly 
dusty  woollen  curtains  and  carpets.  Two 
iron  bedsteads  should  be  provided,  not 
more  than  o  feet  G  inches  wide,  so 
that  the  patient  can  be  reached  equally 
well  from  either  side,  and  may  be  lifted 
from  one  bed  to  the  other.  A  horsehair 
mattress  is  cooler  and  firmer  than  a  feather 
bed,  and  therefore  preferable,  and  open 
iron  spring  bedsteads  are  far  safer  than 
the  old  sacking  and  wool  or  straw  mattress 
under  the  horsehair.  The  covering  ought 
to  be  light  but  warm ;  and  no  one  should 
be  allowed  in  the  room  but  the  patient 
and  her  nurse. 

The  nurse  has  a  very  important  in- 
fluence on  the  result  of  ovariotomy. 
Much  depends  on  her  regarding  all  the 
essential  precautions,  and  managing  for 
the  comfort  and  encouragement  of  the 
patient,  up  to  the  time  of  the  operation; 
and  the  after-treatment  can  be  altogether 
marred  by  any  failure  of  discipline,  or 


neglect  in  fulfilling  every  little -point  of 
the  duties  entrusted  to  hen  What  is 
especially  Avanted  in  a  nurse  for  this  kind 
of  work  is  a  calm,  quick,  decided  way  of 
doing  it ;  an  intelligent  understanding  of 
its  nature  ;  a  readiness  in  comprehending 
the  instructions  given ;  punctuality  and 
exactness  in  carrying  them  out;  and  a 
discriminating  carefulness  in  observing 
and  reporting  all  that  passes  iinder  her 
notice,  and  that  may  be  of  importance  to 
the  surgeon  in  judging  of  the  progress  or 
regulating  the  treatment  of  the  case.  The 
passive,  confiding  docility  of  women  after 
ovariotomy,  who  find  themselves  subject 
to  the  good  understanding  which  exists 
between  a  competent  nurse  and  the  sur- 
geon she  is  serving  under,  is  in  marked 
contrast  with  the  keen  anxious  watchful- 
ness and  feverish  fidgetiness  of  others  less 
fortunate  in  their  attendants,  and  the 
progress  towards  convalescence  is  pro- 
moted or  retarded  in  such  a  way  as  to 
make  very  clear  how  much  the  style  of 
nursing  has  to  do  with  it. 

No  nurse  shoidd  be  entrusted  with  the 
care  of  a  patient  after  ovariotomy  unless 
she  is  well  able  to  use  the  female  catheter 
without  uncovering  the  body  and  expos- 
ing it  to  chill.  She  should  use  the 
catheter  every  G  or  8  hours,  or  as  much 
oftener  as  the  patient  may  wish,  and 
should  preserve  the  urine,  but  not  in 
the  sick-room,  for  the  examination  of 
the  surgeon.  She  should  also  be  well 
practised  in  clearing  the  rectum  by  injec- 
tions, and  expert  in  giving  medicine  or 
food  by  it  when  necessary.  She  should 
know  the  danger  of  bed-sores,  and  the 
mode  of  avoiding  them. 

Very  few  nurses  can  be  entrusted  with 
the  sponges.  The  surgeon  should  always 
see  tnat  they  are  as  pure  as  they  possibly 
can  be  made  before  every  operation.  The 
nurse  should  cut  several  slips  of  adhesive 
plaster,  about  2  inches  broad,  and  long 
enough  to  more  than  half  encircle  the 
body,  and  arrange  a  supply  of  thymol  or 
iodoform  gauze,  salicylic  wool,  and  some 
muslin  bags  filled  with  phenolised  or 
boracic  cotton-Avool,  such  as  those  de- 
vised by  Mr.  Gamgee.  An  india-rubber 
bag  filled  with  hot  water  should  be  ready 
for  use  ;  a  flannel  belt  to  pm  round  the 
body,  and  some  large  safety  pins  to  fasten 
it.  Some  brandy,  one  or  two  pint  bottles 
of  champagne,  and  some  ice,  must  be 
entrusted  to  her  care.  An  enema  bottle, 
holding  an  ounce,  with  an  elastic  tube,  a 


PREPARATION  FOR   OVARIOTOMY 


75 


minim  measure,  and  some  laudanum  ;  good  fire  in  the  room,  and  a  plentiful 
should  be  provided,  so  that  in  case  of'  supply  of  hot  and  cold  water;  and  she 
pain  a  dose  of  it  may  he  injected  into  the  i  ought  to  see  that  all  is  in  such  readiness 
rectum,  A  feeding-cup  is  also  wanted,  that,  after  the  patient  is  in  the  room,  it 
with  which  nourishment  may  be  given  I  may  not  be  necessary  to  send  for  any- 
without  the  patient  rising.  I  tljing,  or  to  open  the  door.     With  some 

It  is  better  that  the  temperature  of ,  few  unusually  nervous  patients  it  may  be 
the  room  should  not  be  so  high  as  was  desirable  to  administer  the  anaesthetic  in 
formerly  supposed  indispensable,  nor  need  another  room,  or  in  bed  in  the  same 
any  attempt  be  made  to  charge  the  atmo-  room,  before  they  are  placed  on  the  table; 
sphere  Avith  moisture.     In  my  first  paper    but,  as  a  rule,  as  soon  as  they  have  emptied 


the  bladder,  patients  may  walk  to  the  table 
andari-ange  themselves  upon  it,  with  some 
little  assistance,  in  the  position  desired  by 
the  surgeon.  The  night-gown  should  be 
pressed  up  towards  the  shoulders.  In 
order  to  have  as  few  assistants  as  possible, 
a  broad  strap  should  be  carried  over  the 
patient's  knees,  and  around  the  table,  and 


on  ovai'iotomy,  I  expressed  my  belief  that 
many  of  the  symptoms,  supposed  to  be 
caused  by  the  operation,  were  in  reality 
due  to  the  confinement  of  the  patient  in 
a  hot  close  room  filled  with  watery  vapour, 
and  I  showed  that  both  patient  and  sur- 
geon were  much  more  comfortable  in  an 
ordinary  atmosphere.  The  temperature 
of  the  room  should  not  be  below  GU° 
Fahrenheit,  but  it  need  not  be  raised  to 
an  uncomfortable  degree  above  this  point. 
The  patient  should  wear  her  ordinary 
night-dress,  warm  woollen  stockings,  and 
a  loose  short  flannel  dressing-jacket.  Any- 
thing tight  round  the  neck  or  body  should 
be  removed.  Even  if  the  bowels  have 
acted  on  the  morning  of  the  day  selected  for 
operation,  the  rectum  should  be  thoroughly 
cleared  out  by  an  injection  of  Avarm  water. 
A  little  good  beef- tea,  with  dry  toast, 
will  be  enough  for  the  morning  meal,  and 
nothing  should  be  eaten  for  4  hours 
before  the  anaesthetic  is  administered.  I 
find  about  2  or  3  in  the  afternoon  a 
better  time  for  operating  than  an  early 
morning  hoiir.  A  patient  Avho  expects 
to  undergo  an  operation  early  in  the 
morning  seldom  sleeps  Avell,  or  she  awakes 
wearied  and  depressed ;  but  if  she  is  to  I  tightly  fastened.  Each  hand  should  also 
get  up  and  does  not  expect  her  fate   to  j  be  securely  fixed  by  a  bandage  to  a  leg  of 


be  decided  till  the  afternoon,  she  sleeps 
better,  and  there  is  time  for  clearing  the 
bowels  after  breakfast.  With  a  warm 
bath  the  night  before,  the  skin  is  in  a 
better   state  for  perspiring.     The  abdo- 


the  table.  The  head  should  be  laid  in  a 
comfortable  position  on  pillows;  and, 
except  the  abdomen  and  face,  the  body 
should  be  covered  Avith  Avarm  light 
blankets  or  flannel.     The  abdomen  should 


men  should  be  thoroughly  cleansed  with  '  be  covered   by  a  waterproof  sheet,  Avith 


soap  and  Av^ater.  It  is  important  that  the 
nurse  should  be  instructed  in  the  use  of 
the  clinical  registering  thermometer,  and 
it  is  ahvays  Avell  to  knoAV  the  morning 
and  evening  temperature  of  a  patient  for 
2  or  3  days  before  operation. 

Tables  on  Avhich  the  patient  is  to  lie 


an  openmg  about  8  inches  long  and  G 
inches  Avide  in  the  middle ;  the  inner 
surfoce  spread  Avith  a  coating  of  adhesive 
plaster  of  about  an  inch  in  Avidth  all 
round  the  opening,  so  that  it  may  adhere 
to  the  skin,  prevent  any  exposure  of  the 
patient,  and  keep  her  body  and  clothing 


for  the  operation,  Avith  foot-pans  or  pails  :  perfectly  dry  and  clean, 
beneath  for  the  reception  of  the  fluid,  and  :  The  draAving  on  the  next  page  shoAVS 
another  table  for  the  instruments,  should  ,  hoAv  I  am  noAv  in  the  habit  of  arrar^g- 
be  placed  opposite  a  AvindoAv  admitting  ;  ing  tAvo  tables  near  a  AvindoAv,  Avith  the 
a  good  light.     The  nurse  should  have  a    patient  covered  upon  them  ;  a  table  for  the 


76 


OVARIAN   AND   ALLIED   TUMOURS 


instruments  being  to  the  right  hand  of  the 
operator.  Steam  spray  apparatus  may  be 
placed  upon  another  table  near  the  feet 
of  the  patient  to  her  left — supposing  the 
surgeon  uses  the  spray. 

The  necessary  instruments  for  a 
simple  case  of  ovariotomy  are  few :  a 
scalpel,  to  divide  the  abdominal  Avail;  a 
director,  to  protect  the  cyst  as  this  division 


is  completed  ;  a  trocar,  to  empty  the  cyst ; 
needles  and  silk,  to  secure  the  pedicle  and 
close  the  wound  ;  with  forceps  and  liga- 
tures, to  secure  any  bleeding  vessels.  But 
there  is,  perhaps,  no  surgical  operation 
where  the  surgeon  may  be  so  met  by 
difficulties  where  he  least  expected  them, 
and  it  so  often  happens  that  instruments 
are  wanted  which  would  not  be  at  hand 


if  only  the  instruments  required  for  an 
ordinary  case  were  taken,  that  it  is  a  safe 
rule  to  take  to  every  case  a  full  supply  of 
instruments,  to  meet  every  emergency. 
Cautery  clamps  and  cauteries  for  cases 
where  the  cautery  is  aj)jilicable,  ligatures 
and  needles  of  different  shapes  and  sizes 
for  cases  where  neither  clamp  nor  cautery 
is  used,  pressure  forceps  for  temporarily 
holding  separated  omentum  or  torn  vas- 
cular adhesions,  and  for  securing  arteries 
by  ligature  or  torsion,  vulsella  specially 
adapted  for  holding  large  cysts,  a  chain 
and  wire  ecraseur,  drainage  tubes  of 
glass,  vulcanite,  or  india-rubber,  and  per- 
chloride  of  iron  should  always  accom- 
pany the  surgeon.  Only  the  instruments 
which  the  operator  thinks  likely  to  be 
required  need  to  be  arranged  on  the  table 


to  his  right,  the  others  in  reserve  should 
be  placed  ready  lor  use  in  a  drawer,  or  on 
a  tiay,  out  of  the  way,  but  close  at  hand. 
All  this  having  been  done,  and  the  table 
with  the  instruments  covered  with  a  towel, 
the  light  subdued,  and  no  other  persons 
present  than  the  operator,  the  adminis- 
trator of  the  anajstlietic,  and  the  nurse, 
the  patient  m:iy  be  brought  into  the 
room. 

Before  proceeding  to  describe  the 
various  steps  of  the  operation,  a  few  lines 
may  be  given  to  the  consideration  of  the 
anoisthetic,  ar,d  to  an  account  of  the  most 
inii)ortant  instruments  which  I  use. 

In  all  my  earlier  operations  chloroform 
was  the  anaesthetic  given.  Vomiting 
following  the  operation,  and  continuing 
with    the  distressing   persistency   known. 


PREPARATION  FOR  OVARIOTOMY 


77 


as  *  chloroform  sickness,'  was  very  fre- 
quently observed,  in  some  cases  led  to 
great  danger,  and  even  became  a  principal 
cause  of  fatal  results.  I  tried  sulphuric 
ether;  but  the  quantity  necessary,  the 
diffusion  of  the  vapour,  the  irritating 
cough  it  produced,  and  the  difficulty  of 
inducing  complete  anaesthesia  by  it,  in- 
duced me  to  search  for  a  better  anaesthetic. 
I  tried  a  mixture  of  chloroform  and  ether 
in  different  proportions,  but  soon  became 
aware  that  the  patient  was  at  first  only 
affected  by  the  lighter  vapour  of  the 
ether,  and  was  then  subjected  to  the 
action  of  chloroform  just  as  she  was  least 
able  to  bear  it.  The  addition  of  alcohol 
to  the  ether  and  chloroform  made  a  mix- 
ture which  appeared  to  answer  better ; 
and  I  was  trying  this  triple  combination 
when  Dr.  Richardson  brought  the  bichlo- 
ride of  methylene  before  the  profession. 

An  impression  has  prevailed  that  bi- 
chloride of  methylene,  or  chloromethyl,  as 
it  may  be  more  conveniently  called,  is 
only  useful  for  short  operations,  and  that 
it  cannot  be  safely  administered  for  more 
than  1  or  2  minutes.  But  as  my  ex- 
perience would  show  that  this  commonly 
expressed  opinion  is  the  very  reverse  of 
the  truth,  it  seems  to  be  my  duty  to  make 
known  what  I  have  seen  of  the  use  of 
chloromethyl  in  general  surgery. 

The  first  surgical  operation  in  which 
chloromethyl  was  ever  used  was  a  case  of 
ovariotomy,  which  I  performed  in  October 
1867.  The  sleep  produced  was  of  the 
simplest  and  gentlest  character,  and  the 
operation,  which  lasted  35  minutes,  was 
quite  painless. 

This  was  my  229th  case  of  ovario- 
tomy. I  have  now  done  ovariotomy 
1,138  times;  and,  with  the  exception  of 
about  10,  where,  for  some  reason  or  other, 
chloroform  was  used,  chloromethyl  was  the 
anaesthetic  employed.  In  some  200  other 
cases  of  gastrotomy,  and  in  more  than  500 
operations  of  more  or  less  severity — such 
as  herniotomy,  amputation  of  the  breast, 
removal  of  mammary  or  other  tumours,  or 
of  hasmorrhoids,  and  plastic  operations  for 
the  cure  of  vaginal  fistula  or  ruptured 
perineum — chloromethyl  has  been  admi- 
nistered. In  very  few  of  these  operations 
was  the  condition  of  insensibility  to  pain 
maintained  for  less  than  5  minutes.  In  a 
few,  it  was  kept  up  from  45  minutes  to  an 
hour  or  more ;  and  I  should  think  the 
average  would  be  about  1 5  minutes.  Yet 
I  have  never  been  at  all  uneasy  in  any  one 


of  these  cases,  either  during  the  adminis- 
tration of  the  anassthetic  or  from  any  sub- 
sequent ill  effects  fairly  referable  to  it. 
Whereas,  with  chloroform  I  never  felt  quite 
at  ease  ;  and, although  I  never  lost  a  patient 
during  operation,  I  have  three  times  had 
to  resort  to  artificial  respiration.  I  have 
very  often  seen  patients  suffer  so  much 
from  chloroform-vomiting  for  many  hours 
after  operation,  that  the  result  has  been 
imperilled.  And  in  a  few  cases  death  has 
been  in  some  measure  due  to  the  vomiting. 
It  is  quite  true  that  chloromethyl  is  not 
quite  free  from  the  disadvantage  of  causing 
nausea  and  occasional  sickness;  but,  in 
my  experience,  this  is  almost  the  rule  with 
chloroform,  whereas  with  chloromethyl  it 
is  certainly  exceptional.  I  think  after  this 
evidence  it  must  be  admitted  that  the 
anaasthetic  employed  is  a  good  one.  In 
some  cases  less  than  2  drachms  was  used, 
and  very  rarely  more  than  6  drachms.  A 
patient  may  be  kept  in  a  state  of  perfect 
unconsciousness  throughout  a  prolonged 
operation  with  methylene  administered  by 
the  apparatus  devised  by  Dr.  Junker.  The 
patient  does  not  inhale  the  undiluted  va- 
pour of  methylene,  but  air  which  seldom 
contains  more  than  2  per  cent,  and  never 
more  than  4  per  cent,  of  the  vapour. 
The  fluid  itself  can  only  be  blown  into 
the  face  piece  by  a  careless  administrator. 
Scarcely  any  of  the  vapour  escapes  into 
the  room ;  neither  the  surgeon  nor  the 
assistants  are  affected  by  it.  A  patient 
very  seldom  becomes  pale ;  she  sleeps 
quietly,  awakes  quietly,  is  not  often  sick, 
and  seldom  has  much  bronchial  irritation 
referable  to  the  chloromethyl.  Indeed, 
she  gains  all  the  advantages  of  complete 
ansesthesia  with  fewer  drawbacks  than  by 
the  use  of  any  other  anaesthetic  I  know 
of. 

The  trocar  used  in  ovariotomy  by  all 
the  earlier  operators  was  an  ordinary  trocar 
of  full  size.  The  instrument,  now  suffi- 
ciently well  known  and  described  as  my 
ovariotomy  trocar,  I  have  used  for  several 
years  past,  and  have  been  well  satisfied 
with  it. 

In  1871,  Dr.  Fitch  made  the  outer  tube 
cutting,  and  protected  it  by  pushing  the 
inner  tube  forward.  He  also  lengthened 
and  curved  the  end  of  the  canula  upon 
which  the  tube  is  fixed,  enabling  us  to 
use  an  ordin;iry  india-rubber  tube,  without 
fear  of  stopping  the  current  by  its  bending. 
Whether  my  old  ovariotomy  trocar  or  the 
instrument  with  this  modification  be  used 


•8 


OVARIAN   AND  ALLIED   TUMOURS 


(as  shown  in  the  drawing  on  page  86),  a 
cyst  when  punctured,  and  partly  empty, 
is  fixed  on  to  the  canula  by  the  spring 
hooks,  so  that  trocar,  ligature,  and  vul- 
sellum  are  united  in  one  instrument,  and 
a  large  cyst  may  be  emptied  an  1  withdrawn, 
without  any  fear  of  its  contents  escaping. 

As  aids  to  the  hooked  trocar  in  draw- 
ing out  a  cyst,  or  in  holding  a  cyst  which 


has  been  opened,  while  the  septa  of  inner 
cysts  are  being  broken  up  and  the  contents 
brought  out,  hooked  forceps,  or  vulsella  of 
different  kinds,  are  often  necessary.  The 
best  of  these  instruments  is  that  known 
as  Nelaton's  vulsellum.  It  holds  the  cyst 
very  securely,  does  not  slip  nor  tear  the 
cyst.  The  essential  or  grasping  part  of  the 
instrument  is  shown  in  the  upper  drawing. 


The  clamp  which  is  used  for  temporary 
compression  of  the  pedicle  when  we  intend 
to  trust  to  the  cautery  for  stopping  bleed- 
intr  from  the  divided  vessels,  is  known  as 
the  Cautery  Clamp.     The  instrument  was 
devised  by  Clay,  of  Birmingham,  to  stop 
bleeding  from  vessels    in   the    omentum 
separated  from  the  cyst.     It  is  to  him  we 
are  indebted  for  the  principle  of  combining 
compression  and  cauterisation  in  the  sup- 
pression   of   ha?morrhage.      The    cautery 
clamp  not  only  securely  holds  the  pedicle, 
but  so  firmly  compx-esses  the  portion  in- 
cluded within  the    blades,  that  alone   it 
would  be  almost  sufficient  to  control  the 
bleeding;   but  when  the  divided  edge  of 
the  pedicle  is  seared  by  the  actual  cautery, 
the  effect  of  compression  is  assisted  by  the 
line  of  eschar  at  the  cauterised  part.     The 
blades  of  the  clamp  being  heated  by  the 
cautery,  the  compressed  part  of  the  pedicle 
is  also  heated,  the  blood  in  its  vessels  is 
coagulated,  and  when  the  clamp  is  removed 
a  thin  band  almost  like  wash-leather,  with 
the  seared  edge,  becomes  a  very  efficient 
safeguard  against  bleeding.    Baker  Brown 
was  the  first  to  apply  it  to  the  pedicle. 
I  and  others  modified  the  instrument  by 
making  it  broader,  by  adding  a  guard  to 
prevent  slipping  of    the  cautery,  and  an 
ivory   or  talc    shield    to  protect  the   soft 
parts  from  the  action  of  the  heated  clamp, 
liut  Dr.  Keith,  after  many  trials  of  this 
and    other    clamps,     finds    the    original 
instrument    of  Baker   Brown  to   be   the 
best. 

The  cauterising  irons  used  by  Baker 
Brown  were  the  ordinary  conical  irons, 


with  a  sharp  edge,  used  in  firing  joints. 
With  these  instruments  red  hot,  he  divided 
the  pedicle,  as  shown  in  this  cut,  the  tu- 
mour being  held  up  by  an  assistant.  This 
was  a  tedious  and  troublesome  process ; 
and  I  found  that  the  same  end  was  attained 
by  cutting  away  the  cyst  an  inch  or  two 
from  the  clamp,  and  then  burning  all  the 
tissue  that  projected  beyond  the  sur- 
face of  the  clamp.  Flat  irons  answered 
this  purpose  better  than  the  conical  ones. 
The  galvanic  cautery  answers  equally 
well,  and  would  be  generally  preferred, 
if  it  were  possible  always  to  secure 
efficient  battery  action ;  but  as  this  is 
uncertain,  Paquelin's  cautery  has  been 
employed.  Dr.  Keith  adheres  to  the 
original  form  of  conical  iron  heated  in 
the  fire.  I  believe  it  is  of  very  little 
consequence  which  of  the  cauteries  is 
used,  provided  the  clamp  exerts  sufficient 
compressing  force,  and  time  is  taken  to 
cauterise  slowly,  so  that  the  pedicle  is 
subjected  to  the  somewhat  prolonged  in- 
fluence of  heat. 

The  ordinary  chain  ecraseur  has  been 
used  successfully  in  dividing  the  pedicle. 
I  believe  I  was  the  first  to  adopt  this  prac- 
tice, but  although  the  case  proved  success- 
ful, I  was  so  fearful  of  secondary  bleeding 
that  I  have  never  repeated  the  experiment. 
When  the  ecraseur  is  ust-d  with  wire,  not 
to  divide  the  pedicle  but  simply  to  secure 
it  in  a  kind  of  clamp,  a  nut  and  screw 
allow  the  handle  to  be  removed. 

I  have  in  anotner  chapter  alluded  to 
cases  which  have  occurred  in  my  own 
practice  where,  long  before  the  operation, 


PREPARATION   FOR  0^'ARIOTOMY 


79 


the  pedicle  had  given  way  from  twisting 
by  rotation  of  the  tumour,  and  tlie  cyst 
had  received  its  whole  blood  supply 
tlu'ough  omental  vessels.  There  can  be 
no  question,  therefore,  as  to  the  feasibility 
of  tearing  through  a  pedicle,  or  of  twist- 
ing off  an  ovarian  tumour.  Maisonneuve 
was  the  first  to  practise  this  twisting  in 
ovariotomy;  he  twisted  the  cyst  round 
and  round  iintil  the  pedicle  gave  way. 
Macleod,  of  Glasgow,  improved  upon  this 
practice,  and  Hilliard,  the  Glasgow  surgical 
instrument-maker,  modified  some  of  the 
instruments  used  by  veterinary  surgeons 
in  castration,  in  order  to  hold  the  pedicle 
securely  with  one  hand  while  the  cyst  is 
held  and  twisted  with  the  other.     Macleod 


has  had  one  successful  case,  and  his  example 
has  been  followed  with  good  results  in 
Leeds.  It  is  possible  that  there  may  be 
cases  where  this  method  may  be  preferable 
to  the  ligature  or  the  cautery,  but  I  can 
say  nothing  on  this  point  firom  personal 
experience. 

As  bleeding  vessels  low  down  in  the 
pelvis  may  have  to  be  found  and  secured 
where,  the  patient  lying  opposite  the  light, 
the  pelvis  is  in  deep  shadow,  the  surgeon 
should  be  provided  with  a  hand  mirror  to 
reflect  light  to  the  bottom  of  the  pelvis. 
On  a  clear  day  this  gives  quite  light 
enough,  but  in  dark  weather,  or  when 
operating  late  in  the  day,  a  candle  lamp, 
with  a  reflecting  concave  mirror,  is  service- 


able. Collin's  lamp  is  handy,  but  too 
smalh  A  policeman's  '  bull's-eye,'  or  a 
good  carriage  lamp,  is  generally  to  be 
had,  and  by  the  use  of  accumulators  a 
good  reflected  electric  light  may  now  be 
obtained. 

With  regard  to  the  other  instruments, 
it  can  only  be  necessary  to  repeat,  that 
the  surgeon  should  be  prepared  with 
scalpels,  a  probe-pointed  bistoury,  a  broad 
Key's  director,  fine  strong  pure  ligature 
silk,  straight  needles,  forceps,  and  scissors. 

I  have  for  many  years  used  forceps 
with  long  handles,  which  answer  all  the 
purposes  of  '  bull- dogs,'  as  well  as  of 
artery  and  torsion  forceps.  The  catch  at 
the  handles  serves  to  fix  the  instrument, 
and    the   short,    roughened   points    stop 


bleeding  completely,  and  enable  the  sur- 
geon to  twist  the  vessel  if  he  wishes. 

The  forceps  of  Pean  and  Ko^berle 
are  either  curved  or  angular.  But  both 
have  the  disadvantage  of  a  space  between 
the  blades,  which  admits  of  entancrle- 
ment  of  one  instrument  Avith  another,  or 
of  the  passage  of  omentum  or  other 
structures.  This  was  a  fault  in  my  own 
earlier  instruments.  It  has  been  com- 
pletely corrected  in  the  later  instruments 
without  at  all  lessening  the  compressing 
power  exerted  on  the  vessel. 

The  handles  meet  without  leaving  any 
opening  between  them.  The  rings  do  not 
admit  the  thumb  and  finger  too  far ;  and 
the  end  which  compresses  the  vessel  is  so 
bevelled,  that,  if  it  be  desirable  to  apply 


80 


OVARIAN  AND  ALLIED  TUMOURS 


a  ligature,  the  silk  will  easily  slip  over  tlie 
forceps,  and  not  tie  the  blades  together. 
Thus  my  instrument  is  not  only  useful  in 
forci-pressure  and  in  torsion,  but  enables 
the  surgeon   to  dispense   with  any  other 


kind  of  artery-forceps  if  he  wish  to  apply 
a  ligature. 

The  distal  end  of  the  larger  forceps 
which  I  use  for  holding  the  pedicle  in 
ovariotomy,    or   any   mass   of    tissue    in 


other  operations  where  the  temporary 
command  of  bleeding  or  oozing  vessels  is 
urgent,  made  upon  the  same  principle,  is 
here  represented  of  its  ordinary  size. 
The  pressure  in  use  is  ascertained  to  be 
in  pounds  avoirdupois : 


Large  forceps — 1^  in.  fulcrum — object 
1  millimetre  : 

First  catch    Secoml  catcli    Third  catch    Fourth  catch 
20-10  82-8  47-8  60-0 

All  the  instruments  in  known  numbers 
are  placed  on  a  table  near  the  feet  of  the 


patient  and  the  right  hand  of  the  operator, 
in  shallow  dishes,  filled  with  a  2  per  cent, 
solution  of  phenol.  The  smaller  forceps 
are  more  conveniently  arranged  in  up- 
right trays,  to   which  they  are  returned 


immediately  after  use.  A  certain  given 
number  being  taken  and  counted  before 
the  operation  is  begun,  should  also  be 
carefully  counted  before  the  abdomen  is 
closed. 


CHAPTER  VII 

THE    OPERATION   OF  OVARIOTOMY 

DIVISION  OF  THE  ABDOMINAL  WALL  ;  SITUATION  AND  LENGTH  OF  INCISION  ;  SEPARATION  OF 
THE  CYST  ;  EMPTYING  AND  REMOVAL  ;  TREATMENT  OF  THE  PEDICLE  ;  SPONGING  OF 
THE    PERITONEUM  ;    CLOSURE    OF    THE    WOUND 


We  shall  now  suppose  that  the  instruments 
have  all  been  placed  where  the  surgeon 
can  reach  them  without  moving  from  his 
post ;  that  the  patient  has  been  placed  on 
the  tabic,  secured  there  by  the  thigh  strap 
nnd  the  wristbands,  covered  by  the  ad- 
hesive waterproof  sheet,  and  broUL'ht 
under  the  influence  of  the  anaesthetic. 
The  surgeon,  standing  on  the  right  side 
of  the  patient,  with    his  right    hand  to- 


wards the  light,  has  one  assistant  on  his 
left  hand,  and  another  facing  him  on  the 
left  of  the  patient.  Nurses,  with  sponges 
and  the  necessary  articles  already  enume- 
rated, are  also  behind  and  to  the  left  of 
the  patient,  while  the  administrator  of  the 
ana-'Sthetic  stands  at  her  head,  as  shown 
on  page  7G.  All  is  ready  for  the  first  step 
of  the  operation,  and  we  have  now  to  con- 
sider the  situation  and  length  of — 


THE   OPERATION   OF  OVARIOTOMY 


81 


THE    INCISION    OF    THE    ABDOMINAL    WALL 

In  all  my  cases  the  linea  alba  has  been 
selected  as  the  seat  of  incision,  and  in  a 
very  large  majority  of  the  cases  on  record 
other  operators  have  selected  the  same 
situation.  In  some  few  cases  the  incision 
has  been  intentionally  carried  either  to 
the  right  or  left  of  this  line.  One  o£  the 
linea3  serailimares  has  been  occasionally, 
though  very  rarely,  selected ;  and  in  some 
few  cases  oblique  or  transverse  incisions 
have  been  made.  Thus  Dr.  Atlee  in  one 
successful  case  made  an  incision  17  inches 
long,  from  the  symphysis  pubis  to  the 
middle  of  the  crest  of  the  right  ilium. 
Blihring  made  an  incision  at  the  outer 
border  of  the  external  obhque  on  the 
right  side  from  the  false  ribs  to  the  crest 
of  the  ilium. 

In  one  of  the  earliest  cases  in  England, 
Mr.  King  made  a  vertical  incision,  7  or  8 
inches  long,  to  the  right  of  the  umbilicus, 
and  another  4  inches  long  at  right  angles, 
extending  towards  the  spine.  In  this  case 
no  tumour  could  be  found,  and  the  patient 
recovered. 

Haartmann  made  an  incision,  6  inches 
long,  parallel  with  Poupart's  ligament ; 
and  Dorsey  a  vertical  incision  8  inches 
long  met  by  a  transverse  incision  in  the 
left  side  6  inches  long.  These  are  the 
principal  examples  on  record  of  oblique 
or  transverse  incisions.  Vertical  incisions 
to  one  or  other  side  of  the  linea  alba  have 
been  less  uncommon. 

McDowell,  in  his  1st  and  2nd  cases, 
made  his  incisions  9  inches  long,  3  inches 
from  and  parallel  to  the  left  rectus.  In 
his  subsequent  cases  he  seems  to  hare 
selected  the  linea  alba. 

Some  writers,  as  Hamilton,  who  de- 
scribes his  incision  as  'corresponding  to 
the  inner  margin  of  the  right  rectus,' 
merely  express  in  other  words  division 
of  the  linea  alba.  The  object  is  to  avoid 
either  of  the  recti  muscles.  The  only 
operator,  so  far  as  I  know,  who  prefers 
division  of  one  of  the  muscles,  is  Storer, 
of  Boston,  who  says,  '  I  differ  from  most 
operators  in  that  I  prefer  making  the  sec- 
tion in  the  track  of  a  rectus  muscle  rather 
than  in  the  linea  alba,  being  thus  much 
more  certain,  from  the  nature  of  the  tissue 
divided,  of  a  primary  reunion.' 

As  I  do  not  believe  it  possible  that  a 
divided  and  reunited  muscle,  even  when 
complete  imion  results,  can  form  so  firm, 
unyielding,  and  perfect  a  portion  o£  the 


abdominal  wall  as  the  muscle  in  its  normal 
state — as  1  do  not  think  that  division  of 
the  muscle  can  make  union  of  the  skin, 
peritoneum,  or  cellular  tissue  more  certain 
or  complete — and  as  I  have  never  seen 
want  of  union  when  the  recti  had  been 
carefully  avoided,  I  always  endeavour  to 
divide  the  linea  alba  accurately,  without 
opening  the  sheath  of  either  rectus. 

It  is  not  often  easy  to  do  this,  for  gene- 
rally either  the  weight  o£  the  tumour  has 
drawn  the  recti  to  one  side,  or  the  muscles 
have  been  spread  out  over  the  surface 
of  the  cyst.  Anato?nicalh/,  it  appears  a 
matter  of  some  importance  not  to  opeu 
the  sheath  ;  but,  although  it  is  well  to  try 
to  hit  the  linea  alba  exactly,  it  does  not 
appear  of  much  importance  surgically  if 
one  edge  of  the  muscle  be  exposed,  or  if 
a  division  be  made  through  the  muscle 
parallel  with  the  course  of  its  fibres.  If 
the  incision  be  extended  above  the  um- 
bilicus, it  is  better  to  carry  it  round  to 
the  left  side,  because  the  round  and 
suspensory  ligaments  of  the  liver  pass 
diagonally  upwards  and  backwards  at- 
tached to  the  sheath  of  the  right  rectus, 
and  might  be  wounded  if  the  incision 
were  carried  either  directly  through  the 
umbilicus  or  to  the  right.  In  some  cases 
a  wound  of  the  ligaments  might  not  be  of 
consequence,  but  in  others  it  might  lead 
to  serious  heemorrhage,  as  the  embryonal 
umbilical  vein  is  not  always  entirely  obli- 
terated, but  remains  patent,  and  is  some- 
times of  considerable  size. 

When  the  linea  alba  is  chosen  for  the 
incision  the  following  structures  are  suc- 
cessively divided : 

1.  The  skin. 

2.  The  subcutaneous  areolar  tissue, 
with  fat  of  varying  thickness. 

3.  The  interlaced  fibres  of  the  aponeu- 
roses of  the  abdominal  muscles  constitut- 
ing the  linea  alba. 

4.  Layers  of  the  fascia  transversalis 
with  more  or  less  fat.  The  uppermost 
layer  adheres  closely  to  the  linea  alba. 
The  deepest  layer  is  only  very  loosely 
connected  with  the  peritoneum. 

5.  The  peritoneum. 

But  this  normal  arrangement  is  often 
much  modified.  When  there  is  muck 
oedema  of  the  abdominal  wall  the  different 
layers  may  be  widely  separated,  and  appear 
as  if  increased  in  number;  or  they  may  be 
agglutinated  together  by  previous  inflam- 
matory processes;  and  the  recti  muscles 
I  are  otten  carried  so  much  to  one  side  by 

Q 


82 


OVARIAN   AND   ALLIED   TUMOURS 


the  tumour  that  it  is  almost  impossible  to 
avoid  exposure  or  division  of  some  of 
their  fibres. 

The  anatomical  question  may,  perhaps, 
be  studied  by  the  assistance  of  the  ac- 
companying diagrams,  which  show  the 
structures  necessarily  divided  if  the  ab- 
dominal wall  be  cut  through — 

1.  AloD";  the  linea  alba. 


2.  Through  one  of  the  recti  muscles, 
and 

3.  Along  one  of  the  linese  semihmares. 
The  effect  of  division  in  the  upper  and 

lower  part  of  the  linea  alba  is  also  shown. 
Let  diagram  (No.  1)  represent  the 
layers  just  enumerated  as  divided,  when 
an  incision  is  made  through  the  anterior 
abdominal  Avail  at  the  linea  alba. 


No.  1. 


a.  Umbilicus. 

b.  Skin. 

c.  Linea  alba. 

d.  Symphysis. 


e.  Peritoneum. 

/.  Superficial  layer  of  areolar  tissue. 

g.  Deep  layer  of  areolar  tissue. 

/i.  Areolar  tissue  ricli  in  fat,  or  perimysium  internum. 


The  following  diagram   (No.  2)   will  j  on  either  side  of  the  linea  alba  through 
then  show    how    many    additional  layers    one  of  the  recti  muscles, 
must  be  divided  if  the  incision  be  carried  |         The  diagram  (No.  3)  shows  the  layers 


No.  2. 


o.  Umbilicus. 

b.  Skin. 

c.  The  rectus  muscle  with  its  inserip- 

tiones  tendinea3. 

d.  Symphysis  jjubis. 

e.  I'l'ritomuin. 

f.  Superficial  layer  of  areolar  1  issue. 
(J.  Deep  layer  of  areolar  tissue. 

divided  if  the  incision  be  made  along  one 
of  the  linea;  semilunares. 

All  of  the  structures  which  make 
up  the  anterior  al)dominal  wall,  and  are 
arranged  in  the  layers  represented  in  the 
preceding  diagrams,  arc  of  some  interest 
to  the  surffcon. 


A.  Perimysium  internum. 
/.  Aponeurosis    of   e.\tcrn.^l    oblirjue 

muscle. 
k.  Aponeurosis    of   internal    oblique 

muscle. 
/.  Ajjoneurosisoftransversalis  muscle. 
m.  Fascia  transvcrsalis. 


1.  21ie  integument  is  thinner  and  more 
sensitive  between  the  sternum  and  the 
umbilicus  than  in  other  regions.  Around 
the  umbilicus  it  is  not  movable,  being 
firmly  connected  with  the  aponeurotic  ring 
by  cellular  tissue  which  contains  no  fat. 
But  when  fluid,  ovarian  or  ascitic,  is  free 


THE   OPERATION   OF   OVARIOTOMY 


83 


in  the  peritoneal  cavity,  it  often  pasf^es 
through  the  ring,  and  distends  the  integu- 
ments into  the  sembhincc  of  an  umbilical 
hernia.  Below  the  umbilicus  the  integu- 
ment is  very  often  found  ojderaatous,  and 
any  linese  albicantes  present  then  become 
very  prominent ;  this  condition  does  not 
seem  to  interfere  with  union  of  the  in- 
cision by  first  intention. 

No.  3. 


a.  Crest  of  the  ilium. 

b.  Skin. 

e.  Peritoneum. 

J'.  Superficial  layer  of  areolar  tissue. 
p.  Fascia  superticialis. 
/).  Perimysium  internum. 
i.  Aponeurosis  of  external  oblique  muscle. 
/;.  Aponeurosis  of  internal  oblique  muscle. 
/.  Aponeurosis  of  the  transversalis  muscle. 
m.  Fascia  transversalis. 

2.  The  subcutaneous  areolar  tissue  in 
some  parts  of  the  abdominal  wall  presents 
two  distinct  and  separate  layers.  The 
superficial  layer  is  rich  in  fat-cells,  and 
contains  the  superficial  blood-vessels.  The 
deeper  layer  has  more  the  character  of  a 
fibrous  fascia,  and  is  the  proper  fascia 
superficialis.  This  separation  is  most 
apparent  in  the  hypogastric  and  inguinal 
regions,  and  is  more  easily  demonstrated 
in  old  than  in  young  persons.  Of  the 
blood-vessels  which  ramify  in  the  cellular 
tissue,  only  the  external  epigastric  artery 
and  vein  are  of  praatical  interest.  The 
artery,  or  one  of  its  larger  branches,  is 
more  likely  to  be  divided  Avhen  the  in- 
cision is  along  one  of  the  line£B  semilunares, 
or  through  one  of  the  recti  muscles,  than 
Vvhen  the  linea  alba  is  divided.  But  it 
can  be  readily  tied  before  the  peritoneum 
is  opened.  The  external  epigastric  veins 
are  frequently  enlarged  or  varicose  when 
tumours  obstruct  the  current  of  blood  along 
the  inferior  vena  cava.  In  some  rare  cases 
a  subcutaneous  vein  communicatesthrov.crh 


the  umbilical  ring  with  the  pervious  um- 
bilical vein.  A  slight  deviation  in  the  line 
of  incision  will  often  enable  tlie  surgeon 
to  avoid  enlarged  veins ;  and  if  this  cannot 
be  done,  it  is  advisable  to  stop,  by  i)ressure 
forceps,  the  current  of  blood  througli  the 
vein  before  it  is  divided.  In  this  way, 
what  might  bo  otherwise  a  serious  loss  of 
blood  is  jn-evented.  It  is  not  often  neces- 
sary to  use  a  ligature  after  the  forceps  are 
removed. 

3.  27ie  sheaths  of  the  recti,  complete 
anteriorly,  incomplete  posteriorly  from 
about  2  inches  below  the  umbilicus,  formed 
by  the  aponeuroses  of  the  flat  abdominal 
muscles,  and  terminating  in  the  linea  alba, 
hardly  require  more  tlianapassingmention. 
But  if  much  disturbed  during  the  first 
incision,  abscess  is  Ycry  likely  to  delay 
healing. 

4.  The  recti  and  pyramidales  muscles 
are  almost  always  seen,  and  one  or  other 
may  or  may  not  be  divided  in  ovariotomy. 
When  the  recti  are  unusually  broad  near 
tha  pubes,  the  pyramidales  may  be  absent. 
When  the  recti  are  narrow  below,  the 
pj'ramidales  lying  in  front  of  the  recti,  and 
inclosed  in  the  sheath,  are  inserted  into 
the  inner  border  o£  the  sheath,  half-way 
between  the  pubes  and  the  umbilicus,  or 
even  higher. 

5.  The  fibres  of  the  flat  abdominal 
muscles  cross  each  other  in  different  di- 
rections, embrace  the  recti  muscles,  and 
conjoin  on  the  linea  alba,  forming  a  ten- 
dinous band,  which  is  very  strong  at  the 
pubic  end,  and  broader  and  weaker  at  the 
sternal  end.  The  fibres  of  the  aponeurosis 
on  one  side  continue  across  the  linea  alba, 
and  interlace  with  fibres  coming  from  the 
opposite  side,  forming  meshes  which  in 
the  normal  state  are  very  small,  only  giving 
passage  to  nerves  and  vessels ;  but  which, 
after  great  distension  of  the  abdominal 
wall,  form  apertures  through  which  small 
masses  of  fat  may  escape  from  beneath, 
forming  what  have  been  called  Hernias 
adiposag,  and  often  leading  an  inexperi- 
enced ovariotomist  to  think  that  he  has 
opened  the  peritoneal  cavity,  and  exposed 
the  omentum. 

6.  The  umbilicus  is  merely  one  of 
these  openings  in  the  linea  alba ;  but  the 
occasional  permeability  of  the  embryonal 
umbilical  vein  must  be  borne  in  mind,  as 
well  as  the  fact  that  the  urachus  may 
also  remain  permeable,  and  urine  escape 
from  the  bladder  through  it  at  the  umbi- 
licus.      I   have   never  seen   this   in    the 

o  2 


84 


OVARIAN   AND   ALLIED   TUMOURS 


adult;  but  in  one  case  of  ovariotomy  I 
found  the  urachus,  though  closed  at  both 
endr,  open  for  the  whole  length  of  my 
incision  in  the  abdominal  Avail,  and  filled 
by  small  urinary  concretions.  Usually  it 
is  obliterated,  and  forms  the  vesico- 
umbilical ligament  running  wp  along  the 
linea  alba  from  the  bladder  to  the 
■umbilicus. 

7.  The  deep  fascia,  or  the  layer  of 
areolar  tissue  between  the  iasoia  trans- 
versalis  and  the  peritoneum,  is  very  elastic, 
and  only  loosely  adherent,  so  that  it  is  easy 
to  separate  the  peritoneum  to  a  consider- 
able extent  without  opening  it.  Indeed, 
if  fluid  be  free  in  the  peritoneal  cavity, 
the  membrane  bulges  up,  like  a  bluish 
thin-walled  cyst,  as  soon  as  the  deep  fascia 
is  divided. 

8.  The  peritoneum.     It  must  be  re- 


membered that  the  obliterated  umbilical 
vessels  and  urachus,  passing  from  the 
fundus  of  the  bladder  to  the  umbilicus, 
are  covered  by  the  parietal  peritoneum. 
The  inferior  epigastric  arteries  ascending 
obliquely  from  Poupart's  ligament  to  the 
posterior  surfixce  of  each  rectus  muscle, 
also  lie  between  the  peritoneum  and  the 
integument.  The  fold  from  the  umbilicus 
forming  the  suspensory  ligament  of  the 
liver  has  been  already  alluded  to.  It  is 
with  the  later  steps  of  the  operation  that 
the  peritoneum  and  its  reflections  have 
the  most  important  relations.  In  con- 
nection with  the  first  incision  it  is  only 
necessary  to  add  that  it  must  be  useless 
to  carry  this  incision  nearer  to  the  sym- 
physis pubis  than  the  reflection  of  the  peri- 
toneum from  the  anterior  abdominal  wall 
to  the  bladder;  and  it  is  a  safe  rule  to 


stop  short  of  this  point,  ai:id  not  carry  the 
lower  end  of  the  incision  nearer  than  2 
inches  from  the  symphysis  pubis. 

As  a  rule,  the  abdomen  is  tense,  and 
the  incision  is  made  with  an  ordinary 
scalpel  held  in  the  first  position,  as  shown 
in  this  drawing.  If  the  operation  is  per- 
formed soon  alter  tapping,  and  the  abdo- 
minal walls  are  very  lax,  it  is  convenient 
to  mark,  with  ink  or  chalk,  the  exact  line 
and  extent  of  the  incision  intended  to  be 
made,  and  then,  holding  up  a  fold  of  in- 
tegument, to  transfix  with  rather  a  long 
bistoury,  and  complete  the  incisifin  of  the 
skin  with  one  stroke  of  the  knife.  The 
linea  alba  and  any  fat  behind  the  recti 
muscles  may  then  be  carefully  divided  in 
the  usual  way,  until  the  peritoneum  is 
reached.  A  point  also  which  ought  not 
to  be  forgotten  at  this  stage  of  the  opera- 
tion is  the  possible  expansion  of  the  blad- 


der, behind  the  abdominal  wall,  by  the 
pressure  of  the  tumour.  It  is  sometimes 
found  flattened,  and  extending  above  the 
umbilicus,  covering  a  space  as  much  as  8 
to  9  inches  long,  and  as  much  wide.  I 
gather  from  the  '  Transactions  of  the 
American  Gynecological  Society,'  1881, 
tliat  22  cases  had  been  recorded  in 
which  the  bladder  had  been  accidentally 
o])ened,  of  which  14  were  known  to  have 
died. 

If  there  is  any  fluid  free  in  the  peri- 
toneal cavity,  the  peritoneum  bulges 
into  the  deep  gaj)  made  by  the  incision, 
looking  like  a  dark  thin-walled  cyst,  and 
it  has  oi'ten  been  mistaken  for  a  cyst; 
extensive  separation  has  been  made  of 
.supposed  adhesions,  while  the  operator 
was  really  stripping  the  peritoneum  from 
the  abdominal  wall.  When  the  peritoneum 
bulges  as  just  described,  it  should  always 


THE  Oi'ERATIOX   OF   OVArJOTOMY 


85 


be  opened,  and  the  fluid  allowed  to  escape, 
which  may  be  done  without  wetting  the 
patient  or  its  running  over  the  floor,  if  the 
waterproof  apron  is  so  held  as  to  direct 
the  fluid  into  the  foot-pan  under  the 
table.  Even  if  the  biilging  membrane 
were  not  the  peritoneum,  but  a  thin- 
walled  adherent  cyst,  no  liarm  could  be 
done  by  this  puncture,  as  it  is  certainly 
a  good  plan  to  empty  the  cyst  belbre 
separating  the  adhei^ions.  AVhen  there  is 
no  fluid  free  in  the  peritoneal  cavity,  and 
an  ovarian  C3^st  is  not  adherent,  it  is 
necessary  to  divide  the  peritoneum  very 
carefully,  or  the  cyst  might  be  punctured 
and  its  contents  discharged  into  the  peri- 
toneal   cavity.     The   peritoneum   should 


be    raised    with  a  hook   or  forceps,  the 
double  sharp  hook  of  Adams  answering 


the  purpose  perhaps  better  than  any 
oilier  instrument.  The  membrane  is  then 
divided  by  one  or  two  horizontal  touches 
of  the  knife,  as  shown  in  the  next  draw- 
ing, and  an  opening  made  large  enough 
to  admit  the  insertion  of  a  broad  director. 
The  instrument  known  as  Key's  hernia 
director  is  that  which  I  prefer.  The  end 
is  rounded  in  imitation  of  a  finger-nail ; 
the  groove  does  not  extend  within  half  an 
inch  of  the  point,  and  far  greater  safety 
from  the  danger  of  wounding  overlapping 
intestine  is  thus  attained  than  by  the  use 
of  the  ordinary  narrow  directors,  where 
the  groove  runs  quite  to  the  end.  Upon 
this  director  a  blunt-pointed  bistoury  is 
passed,  and  the  peritoneum  divided  to  the 
full  extent  of  the  incision  in  the  akin. 

On  inquiring  as  to  the  different 
lengths  of  incision  in  1,000  cases,  and 
comparing  the  mortality  per  cent,  with 
incisions  above  and  below  6  inches, 
there  was  found  at  all  stages  of  my  pro- 


gress the  same  difference  of  about  17 
per  cent,  of  deaths  between  the  long 
incisions  and  the  short  incisions.  The 
length  of  the  incision,  however,  is  little 
else  than  an  indication  of  the  gravity  of 
the  case,  as  it  cannot  be  supposed  that 
2  or  3  inches  more  of  simple  division  of 
the  parietes  of  the  abdomen  would  much 
augment  the  danger. 

The  smooth  pearly  aspect  of  most 
ovarian  tumours  is  sufficiently  character- 
istic for  immediate  recognition,  and  free 
movement  of  the  cyst  is  often  visible. 
But,  when  a  cyst  is  adherent,  it  is  often 
extremely  difficult  to  find  out  the  exact 
limits  or  boundary  between  cyst  and 
peritoneum,  and,  rather  than  make  any 
improper  or  dangerous  separation,  it  is 
better  to  extend  the  incision  upwards  and 
downwards  until  some  point  is  reached 
where  the  cyst  is  not  adherent.  From 
that  point  separation  of  adhesions  may  be 
commenced.     When    there    is   much  fat 


in  the  abdominal  wall,  either  in  front  of 
or  behind  the  recti  muscles,  this  should 
be  divided  by  as  clean  a  cut  as  possible, 
going  through  nearly  the  whole  thickness 
of  fat  by  one  stroke  of  the  knife  ;  for,  if 
the  fat  be  much  disturbed,  troublesome 
suppuration  about  the  wound  is  very 
likely  to  occur.  During  the  progress  of 
the  incision  bleeding  may  be  tolerably 
free,  but  very  often  scarcely  any  blood 
is  lost ;  and,  as  soon  as  the  incision  has 
reached  the  peritoneum,  the  wound  should 
be  carefully  cleansed  from  the  blood  by 
soft  linen  or  sponges.  Any  A'essel  seen 
to  bleed  should  be  conipi-essedby  pressure- 
forceps.  It  is  important  to  stop  all  bleed- 
ing from  the  wound  before  the  peritoneum 
is  opened.  It  is  seldom  that  any  large 
vessel  is  divided,  but  if  the  compression 
of  the  forceps  or  torsion  does  not  at  once 
.stop  bleeding,  one  or  more  ligatures  may 
be  used  and  both  ends  may  be  cut  off 
short  close  to  the  knot. 


86 


OVARIAN   AND   ALLIED   TUMOURS 


SEPARATION    OF    THE    CYST 

I  have  j  ust  said  that  if  a  cyst  is  so  closely 
adherent  that  it  is  difficult  to  ascertain  its 
exact  bonndarie?,  it  is  better  to  empty  it 
before  attempting  to  separate  it,  than  to 
run  any  risk  either  of  separating  the 
peritoneum  from  the  abdominal  wall,  or 
of  so  rupturing  the  cyst  that  its  contents 


might  escape  into  the  peritoneal  cavity. 
And  adhesions  to  the  intestine  or  omentum, 
especially  those  at  the  posf-erior  part  of 
the  cyst,  are  also  better  left  until  the  cyst 
is  emptied  and  drawn  out;  the  separa- 
tion being  completed  when  the  parts  to 
be   separated   are   in   full  view.     When 


adhesions  are  loose,  or  not  extensive,  and 
the  cyst  has  been  distinctly  made  out 
after  the  division  of  the  peritoneum,  thead- 
hesions  may  generally  be  easily  separated 
by  one  or  two  fingers,  or  by  inserting  the 
whole  hand  between  the  cyst  and  the 
abdominal  wall — the  palmar  surface  next 
the  tumour,  and  the  fingers  curved  to 
adapt  the  shape  of  the  hand  to  the  con- 
vexity of  the  cyst.  Sometimes  extensive 
adhesions  yield  before  a  very  slight  force, 
but  very  considerable  effort  is  occasionally 
required  to  break  them  down.  Adhesions 
are  very  rarely  so  firm  that  it  becomes 
necessary  to  complete  their  separation  by 
knife  or  scissors ;  when  this  is  the  case,  it 
is  better  to  cut  away  some  small  portion 
of  the  cyst  and  leave  it  adhering  to  the 
intestine  or  other  viscus,  than  to  do  any 
damage  by  attempting  to  take  away 
every  fragment  of  the  cyst.  I  have, 
however,  very  rarely  done  this ;  as,  aiter 
the  cyst  has  been  separated  from  the 
abdominal  wall,  emptied  and  drawn  out 
with  the  adhering  portions  of  intestine 
and  omentum,  I  have  almost  always 
been  able  to  make  complete  separation, 
although  great  care  has  often  been  neces- 
sary to  avoid  injury  to  the  intestine.  I 
have  twice  opened  intestine  when  separat- 
ing adhesions,  but  accurate  adaptation  of 
the  peritoneal   coat  by  suture  has  pre- 


vented any  mischief.  In  one  case  I  re- 
moved about  3  inches  of  diseased  and 
adlierent  intestine,  and  obtained  complete 
union  of  the  ofien  ends  by  2  rovvs  of 
suture  through  the  peritoneal  coat  only. 
Occasionally,  instead  of  separating  ad- 
hering omentum,  it  is  better  to  divide  j 
it  at  some  unattached  point,  after  the 
application  of  a  ligature  or  pressure-  | 
Ibrceps,  allowing  the  adhering  portion  to 
be  removed  with  the  cyst.  The  per- 
manent   suppression    of   bleeding    from  i 


separated  omentum  or  parietal  adhesions 
is  left  until  after  the  emptying  of  the 
cyst,  securing  the  pedicle,  and  cutting 
away  the  tumour. 

EMPTYING    AND    REMOVAL    OF    CYST 

When  the  tumour  is  found  fi-ee  from 
adhesions,  or  after  the  separation  of  slight 
adhesions,  the  next  step  is  to  empty  the 
cyst.  Tlie  syphon  trocar  with  spring- 
hooks,  held  in  the  right  hand,  should   be 


THE   OPERATION  OF  OVARIOTOMY 


87 


pushed  into  the  most  prominent  part  of 
the  cyst,  if  this  appear  to  be  simple  ;  if 
muhilocular,  into  that  chamber  which  is 
likely  to  contain  the  largest  quantity  of 
fluid.  The  point  is  to  be  drawn  within 
the  canula  by  means  of  the  thumb-piece. 
After  a  portion  of  the  fluid  has  been 
drained  olF,  and  the  cyst  has  become  more 
flaccid,  it  is  drawn  higher  up  over  the 
canula,  and  fixed  between  the  prongs  of 
the  spring-hooks,  which,  if  properly  ad- 
justed, will  hold  the  cyst-wall  tightly 
around  the  canula.  After  the  first  cavity 
has  been  emptied,  a  second,  a  third,  and 
more  if  necessary,  may  be  tapped  suc- 
cessively without  removing  the  canula 
from  its  hold,  merely  by  pushing  the 
trocar  forward  and  thrusting  it  through 
the  septum  which  seimrates  the  emptied 
from  the  adjacent  full  cavity.  In  this 
manner  the  whole  tumour  may  be  emp-  I 
tied  of  its  fluid  contents,  and  its  bulk  so  I 


reduced  tliat  it  may  be  drawn  through  the 
abdominal  opening  without  undue  force. 
In  a  case  where  there  are  several  cysts 
which  cannot  be  tapped  one  through  the 
other,  they  must  be  emptied  singly,  either 
by  tlie  same  trocar  or  by  another.  Great 
care  must  be  taken,  if  the  same  trocar  be 
used,  not  to  perforate  the  main  cyst  Avail, 
lest  some  fluid  should  escape  into  the 
abdominal  cavity. 

Having  succeeded  in  reducing  suffi- 
ciently the  size  of  the  tumour,  the  surgeon 
then  draAvs  it  through  the  incision,  at  the 
same  time  breaking  down  any  adhesions 
Avhich  have  not  been  separated  before. 
The  assistant  opposite  to  the  operator  noAv 
places  his  hands  on  either  side  of  the 
incision,  and  prevents  the  prolapse  of  the 
viscera  by  carefully  keeping  the  edges  of 
the  incision  in  close  approximation.  He 
does  this  best  by  placing  the  middle  finger 
of  his  right  hand  inside  the    abdomen. 


hooking  xip  the  abdcminal  wall,  and  then, 
by  the  thumb  on  one  side  of  the  opening 
and  the  forefinger  on  the  other  side,  he 
holds  the  .edges  of  the  opening  close  to- 
gether. And  he  should  not  alloAV  his 
attention  to  be  diverted  from  this  very 
important  part  of  his  duty.  The  assistant 
at  the  operator's  left  hand  supports  the 
cyst  until  it  is  completely  separated,  and 
then  receives  it  in  a  toAvel  or  basin.  No 
traction  Avhatever  is  permitted,  and  the 
greatest  precaution  ought  to  be  observed 
in  this  respect  Avhen  the  pedicle  is  short,  and 
when  there  remain  undivided  adhesions. 

In  order  to  lessen  the  weight  of  the 
tumour,  cysts  Avhich  had  not  been  emptied 
before  may  be  punctured,  and  secondary 
cysts,  if  the  sejjta  are  thin,  may  be  broken 
down  by  the  hand,  as  shoAvn  in  next 
column.  Great  care  ought  to  be  taken 
that  nothing  gravitates  into  the  abdominal 
cavity. 

But  it  Avill  not  be  always  possible  to 
reduce  the  bulk  of  the  timiour  sufficiently 
to  bring  it  through  the  original  incision. 


Tumours  are  sometimes  met  with  Avhich 
consist  of  solid  or  semi-solid  unyielding 
masses,  or  they  are  divided  by  trabecule 
into  small  cavities  filled  Avith  viscid, 
colloid  substance,  Avhich  cannot  be  broken 


doAvn,  and  Avill  not  pass  through  the 
canula.  It  Avill  therefore  become  neces- 
sary to  enlarge  the  incision  upAvards. 
This  is  less  dangerous  than  any  attempt 
at  squeezing  a  large  tumour  through  a 
narrow  outlet ;  either  the  cyst  may  burst, 


88 


OVAKIAN   AND   ALLIED   TUMOURS 


and  its  contents  escape  into  the  abdominal 
cavity,  or  the  edges  of  the  wound  are  so 
bruised  that  union  by  first  intention  might 
be  prevented,  or  the  peritoneum  so  in- 
jured that  i'atal  peritonitis  or  gangrene  | 
may  result.  ] 

In  a  few  of  my  earliest  cases  I  followed 
the  practice  of  previous  operators  of  hav- 
ing flannels,  wrung  out  of  water  at  96^, 
carefully  wrapped  round  the  cyst  or  any 
intestine  that  escaped,  and  to  protect  the 
peritoneal  cavity.  But  I  discontinued 
this  practice,  finding  that  it  was  impossible 
to  prevent  small  filaments  of  wool  separat- 
ing from  the  flannel  and  adhering  to  the 
peritoneum.  Then  I  used  soit  linen 
towels,  but  for  many  years  past  only  soft 
sponges,  although  towels  Avetted  with 
warm  carbolised  water  are  often  useful  to 
cover  a  large  tumour,  and  protect  the 
intestines.  As  the  cyst  is  drawn  through 
the  opening,  a  thin  flat  sponge,  G  or  8 
inches  in  length  and  about  4  in  breadth, 
should  be  pass-ed  inwards  and  left  between 
the  intestines  and  the  open  abdominal 
•wall.  This  serves  the  double  purpose  of 
preventing  escape  of  intestines,  and  pro- 
tecting the  cavity  from  the  entrance  of 
anything  from  outside,  or  from  cooling 
when  spray  is  used. 

TREATMENT    OF    THE    PEDICLE 

The  cyst  or  tumour  having  been 
drawn  out  of  the  abdomen,  any  omen- 
tum or  intestine  adhering  to  its  peritoneal 
coat  separated,  and  any  bleeding  vessel 
secured,  the  intestines  and  peritoneal 
cavity  protected  as  just  described  by  a 
flat  sponge,  tl.-e  next  step  is  to  secure  the 
j>edicle.  This  has  been  done  in  different 
ways,  def;cribed  as  the  intra-peritoneal 
and  the  extra-peritoneal  methods. 

The  older  operators,  McDowell  and 
Clay  especially,  adopted  a  plan  Avhich 
may  be  considered  a  combination  of  both 
methods.  The  pedicle  was  tied,  the 
tumour  cut  away,  and  the  pedicle  was 
left  low  down  in  the  abdominal  cavity, 
surrounded  by  the  ligature,  while  the  ends 
of  the  ligature  were  brought  out  between 
the  edges  of  the  wound.  Half  an  inch  to 
an  inch  of  the  lower  angle  of  the  wound 
was  left  unclfised  to  admit  of  the  passage 
of  the  ligature,  as  an  outlet  for  dis- 
charges, and  for  the  removal  of  the  liga- 
tures and  of  the  tissues  strangulated  by 
them. 

The  intra-peritoneal  method  was  ori- 


ginated, in  1822,  by  Nathan  Smith,  who 
tied  two  arteries  in  the  omentum  with 
strips  of  leather  from  a  kid  glove.  He 
also  tied  two  arteries  in  the  pedicle  with 
leather  ligatures,  and  after  removal  of  the 
tumour,  cut  off  the  ends  of  the  ligatures 
short,  and  left  them  within  the  peritoneal 
ca\ity,  closing  up  the  wound  completely. 
He  was  followed  by  Kogers,  of  New  York, 
Avho,  in  1830,  also  tied  some  large  vessels, 
cut  off  the  ligatures  '  close  to  the  knot, 
and  left  them  to  absorption.'  In  Enfjland 
this  method  was  revived  by  Dr.  Tyler 
Smith,  and  was  followed  by  many  ope- 
rators. After  several  years'  preference  of 
the  extra-peritoneal  method,  it  has  again 
come  into  favour  since  the  adoption  of  the 
antiseptic  system. 

The  other  intra-peritoneal  methods 
include  the  use  of  the  cautery,  the  ecia- 
seur,  the  twisting  off  of  the  tumour, 
torsion  of  its  ve.ssels,  or  the  separate  liga- 
ture of  the  vessels  of  the  pedicle  only  or 
of  the  pedicle  itself.  In  cases  where 
there  is  no  pedicle  and  the  cyst  has  to  be 
enucleated  from  between  the  layers  of  the 
broad  ligament,  ligatures  of  bleeding  ves- 
sels, or  of  parts  of  the  broad  ligament, 
have  almost  compelled  the  adoption  of  the 
intra-peritoneal  method,  since  the  danger 
of  leaving  the  ends  of  the  ligature  passing 
outwards  has  been  understood. 

In  the  extra- peritoneal  method,  instead 
of  shutting  up  the  pedicle  and  ligature, 
or  the  eschar  made  by  the  cautery,  within 
the  peritoneal  cavity,  the  pedicle  and  the 
clamp  or  ligature  securing  it  are  carefully 
fixed  outside  the  closed  wound. 

I  continued  to  folloAv,  though  not 
exclusively,  the  extra-peritoneal  treatn)ent 
of  the  pedicle  for  twenty  years.  The 
clamp  was  put  on  for  the  last  time  in  case 
910,  August,  1878.  I  generally  used  the 
clamp  alone,  sometimes  combined  with  the 
!  ligature,  and  in  a  small  number  of  cases 
I  was  obliged  to  make  a  pin  and  ligature 
serve  as  a  clamp.  My  extra-peritoneal 
treatment  compri-sed  in  all  G91  cases  out 
of  the  1,000  upon  which  the  calculations 
in  this  book  are  founded.  The  mortality  in 
the  entire  group — including  the  greater 
mortality  of  the  earlier  years — was  20  2 
percent.  I  used  the  clamp  alone  023  times, 
losing  20*22  per  cent.  The  clamp  and 
ligature  combined  were  attended  with  a  loss 
of  30-Gl  per  cent.,  and  when  the  pin  and 
ligature  wore  employed  the  deaths  went 
up  to  35 "23  per  cent.  The  bad  nature  of 
the  cases  was  the  cause  of  the  combination, 


THE   OPERATION  OF  OVARIOTOMY 


89 


and  accounts  for  the  great  mortality.  But 
the  clamp  alone  furnished  me  with  a 
lower  rate  of  mortality,  20*22  per  cent., 
than  the  aggregate  of  the  1,000  cases, 
23"2  per  cent.,  and  the  results  from  it  were 
more  favourable  than  those  of  any  other 
kind  of  treatment,  except  that  by  the 
cautery.  It  contrasted  well  with  the 
ligature,  especially  during  the  early  years, 
when  the  returned  ligature  caused  me  a 
mortality  of  49"12  per  cent.,  though  ulti- 
mately this  came  down  to  20' 19  percent., 
as  near  as  possible  the  same  as  the  clamp. 
When  I  looked  into  the  question  of  mor- 
tality among  my  first  500  cases,  and  Ibund 
that  the  clamp  gave  me  a  mortality  of 
5  per  cent,  less  than  that  of  the  mortality 
of  the  whole  series,  and  that  the  ligature 
raised  the  death-rate  19  jier  cent,  above 
that  of  the  clamp,  I  felt  that  I  had  full 
justification  in  persevering  with  the  extra- 
peritoneal treatment.  In  the  second  series 
of  500  cases  the  clamp  mortality  was 
again  below  that  of  the  general  mortality, 
and  within  a  fraction  the  same  as  that  of 
the  cases  in  which  the  ligature  was  used, 
by  this  time  down  to  20*19.  Even  during 
the  last  two  years  of  my  hospital  practice, 
1876-1877,  when  the  diminution  in  the 
rate  of  mortality  from  21   to  10  per  cent. 


took  place,  I  was  using  the  clamp  in  more 
than  two-thirds  of  the  cases.  These 
results  prove  that  I  was  not  wrong  in 
acting  as  I  did;  and  that,  judging  by  all 
the  evidence  forthcoming  at  the  time, 
except  that  witli  regard  to  the  cautery, 
the  clamp  extra-peritoneal  treatment  of 
the  pedicle  was  better  than  any  other  I 
had  adopted.  Upon  the  whole,  it  is 
questionable  whether,  if  I  had  at  an  early 
period  given  up  the  clamp  and  worked 
my  way  with  the  ligature  through  all  the 
difficult  problems  presented  by  the  novel 
conditions  of  the  cases  as  they  successively 
came  under  treatment,  the  result  would 
have  been  better,  or  even  so  good.  At 
any  rate,  such  treatment  was  at  one  with 
the  accepted  doctrines  of  the  day  about 
the  pedicle,  which,  some  contend,  still 
hold  good  in  reference  to  the  stumps  of 
uterine  tumours;  and  it  had  compensa- 
tions for  some  of  the  evils  which,  so  long 
as  the  question  of  contagion  was  over- 
looked, attended  the  use  of  the  ligature. 

Although  the  clamp  is  now  almost 
disused,  it  is  so  simple,  safe,  and  rapid  a 
mode  of  dealing  with  the  pedicle  for  an 
inexperienced  operator,  that  it  is  well  to 
repeat  the  directions  for  its  use  given  in 
my  edition  of  1872. 


The  next  drawings  were  made  when 
I  was  actually  applying  the  form  of  clamp 
which  I  last  used.  The  tumour  was  held 
up  by  one  of  the  assistants,  the  clamp 
passed  round  the  pedicle,  as  shoAvn  in  the 
above  drawing,  and  one  hand  is  shown 
pressing  the  blades  of  the  clamp  together 


by  the  forceps,  which  should  be  held  very 
firm  while  the  screw  which  fixes  the 
clamp  is  being  tightened  by  the  other 
hand,  as  shown  in  the  next  woodcut. 
After  the  tumour  has  been  cut  away,  it  is 
sometimes  necessary  to  tighten  the  clamp 
or  the  screw  still  further.     The  assistant 


90 


OVARIAN   AND   ALLIED   TUMOUES 


keeps  the  abdominal  wall  closed  around 
the  pedicle,  as  shown  in  the  same  drawing, 
also  from  the  life ;  while  the  surgeon, 
holding  the  clamp-forceps  with  his  left 
hand,  fastens  the  screw  with  his  right, 
assisted  by  the  needle-holder. 


It  Avould  seem  unnecessary  to  add 
that  the  surgeon  should  be  careful  not  to 
enclose  anything  but  the  pedicle  in  the 
clamp,  but  the  fact  that  cases  are  on 
record  where  a  portion  of  the  bladder  has 
been  squeezed.^  and  where  one  ureter  has 


been  strangulated,  and  that  I  have  myself 
seen  a  strij)  of  omentum  several  times, 
and  a  coil  of  intestine  once,  very  narroAvIy 
escape  constriction,  shows  that  the  caution 
is  not  uncalled  for. 

The  pedicle  with  the  clamp  should  be 
fixed  as  near  to  the  lower  end  of  the  in- 
cision as  can  be  done  without  traction, 
and  the  edges  of  the  wound  are  brought 
in  contact  around  it. 

Any  superfluous  portion  of  the  pedicle 
protruding  beyond  the  clamp  is  cut  off, 
but  not  quite  close  to  the  clamp,  for  this 
would  lead  to  the  danger  of  the  pedicle, 
as  it  shrinks,  sinking  or  being  drawn  in- 
wards. It  is  as  well  to  leave  about  a 
quarter  of  an  inch  protrudmg  beyond  the 
clamp,  and  this  should  be  touched  with 
solid  perchloride  of  iron,  by  which  the 
tissue  is  tanned  until  it  becomes  quite 
dry  and  is  preserved  from  decomposition. 

Those  Avho  exclusively  follow  the 
intra-peritoncal  method,  and  either  use 
the  cautery  or  return  the  ligature  and 
close  the  Avound,  appear  to  have  been 
influenced '  by  objections  to  the  extra- 
peritoneal method  which  seem  to  me  to 
be  either  groundless  or  trivial.  AVhen 
the  pedicle  is  held  outside  the  wound  by 
a  clamp  or  in  any  other  way,  the  pull 
upon  the  uterus  or  broad  ligament  is  said 
to  be  very  painful ;  but  1  have  seen  a 
good  deal  of  pull  with  very  little  pain, 
and  much  more  severe  pain  in  cases 
where  the  ligature  was  used  than  I  ever 
saw  in  clamp  cases.  So  with  sickness  : 
I  have  seen  as  much  or  more  after  the 


ligature  or  cautery,  as  I  ever  saw  after 
the  clamp.  It  is  said  to  set  up  fetid 
discharge  and  poison  the  wound  or  the 
patient ;  and  so  it  does  if  proper  care  be 
not  taken.  But  if  the  strangulated  part 
of  the  pedicle  which  projects  beyond  the 
clamp  be  well  saturated  with  perchloride 
of  iron,  the  slough  is  tanned  ;  it  becomes 
as  hard  and  dry  as  a  piece  of  leather,  and 
there  is  an  end  to  that  objection.  It  is 
said  to  cause  suppuration  about  the 
wound  ;  but  this,  again,  I  have  seen  both 
after  the  ligature  and  cautery.  I  never 
saw  more  profuse  suppuration  of  the 
stitches  than  in  one  case  where  I  divided 
the  pedicle  with  the  ecraseur,  and  closed 
the  wound  Avith  platinum-wire  sutures. 
Then,  after  the  wound  is  closed,  it  is  said 
to  lead  to  a  reopening  each  month,  and  aa 
escape  of  some  menstrual  fluid.  And 
this  is  true  in  seme — perhaps  in  nearly  a 
third — of  the  cases.  But  if  the  patient 
be  prepared  for  it,  it  is  not  of  the  slightest 
consequence.  The  Fallopian  tube  almost 
always  contracts  completely  after  a  few 
months,  and  there  is  no  further  escape. 
I  can  only  recollect  two  cases  where  it 
has  continued  up  to  the  date  of  the  last 
report  from  the  patient,  and  then  it 
caused  but  slight  inconvenience.  As  to 
any  fancied  impediment  to  the  increase  of 
the  uterus  in  pregnancy,  and  to  its  con- 
traction during  labour,  from  the  adhesion 
of  the  tube  to  the  cicatrix,  I  can  say  that 
many  women  have  had  1  child,  some 
2,  some  3,  and  others  as  many  as  G 
or    7    children ;     and    in    no    case    has 


THE   OPERATION   OF   OVAiaOTOMY 


91 


any  unusual  suffering  been  referred  to 
the  adhesion  of  the  pedicle  to  the  ab- 
dominal wall.  One  real  objection  to  the 
clamp  is  that  it  may  possibly  pull  on 
intestine,  or  a  tense  pedicle  may  strangu- 
late intestine.  But  this  objection  is  of 
little  weight  if  the  use  of  the  clamp  is 
restricted  to  cases  where  the  pedicle  is  so 
long  that  tliere  is  not  much  drag  on  the 
clamp.  Where,  however,  we  have  a 
broad,  thick,  short  pedicle,  or  a  broad 
connection  between  uterus  and  cyst 
rather  than  a  distinct  pedicle,  Ave  have 
the  choice  between  one  or  other  of  the 
intra-peritoneal  methods;  and  since  the 
great  success  which  has  attended  the 
combination  of  antiseptic  ovariotomy  and 
the  complete  intra-peritoneal  treatment 
of  the  pedicle,  the  extra-peritoneal  method 


may  be  considered  as  almost  abandoned, 
and  we  have  to  choose  between  the  liga- 
ture and  the  cautery. 

In  ligaturing  the  pedicle  of  an  ovarian 
tumour,  it  is  never  safe  to  trust  to  a 
ligature  which  does  not  transfix  the 
pedicle,  unless  this  be  very  long  and 
slender.  Many  cases  are  on  record 
where,  after  cutting  away  the  tumour,  a 
simple  encircling  ligature  has  slipped  off, 
and  dangerous  or  iatal  bleeding  has  fol- 
lowed. It  should  be  a  rule,  therefore, 
always  to  transfix  a  pedicle,  and,  accord- 
ing to  its  size,  to  tie  it  in  two  or  more 
portions,  before  the  cyst  is  cut  aAvay.  A 
long  ordinary  needle  double-threaded, 
or  a  long  blunt-pointed,  straight  or  curved 
needle  on  a  handle,  may  be  used.  The 
latter   is    saier   and   more    convenient   if 


the  pedicle  cannot  easily  be  brought 
Avell  outside  the  abdomen.  Both  threads 
having  been  carried  through  the  same 
puncture,  one  is  tied  above  and  one  below 
the  Fallopian  tube,  as  shown  in  the 
sketch,  a  second  turn  having  been  given 
to  the  first  loop  to  prevent  slipping  when 
the  second  turn  securing  the  knot  is 
made.  For  additional  security  a  separate 
ligature  may  be  tied  between  the  two 
first  passed  and  the  uterus.  Mr.  Bryant 
and  some  other  operators  think  it  im- 
portant that  one  loop  should  be  laced 
within  the  other,  as  shown  in  the  lower 
sketch.  But  I  rather  avoid  this,  as  it  is 
possible  that  by  so  tying  the  second  knot 
the  first  may  be  loosened.  Supposing  a 
clamp  or  pressure-forceps  to  have  been 
first  applied,  the  cyst  cut  away,  and  the 
pedicle  then  transfixed  and  tied  between 


the  forceps  and  the  uterus,  the  clamp 
must  be  loosened  or  the  forceps  removed 
before  the  ligatures  are  tightened.  If 
this  is  not  done,  the  knot  cannot  be  tied 
so  tight  as  to  be  secure  after  the  clamp 
is  removed.  As  the  clamp  is  taken  off, 
the  tissues  compressed  by  it  retract,  and 
are  apt  to  slip  from  under  the  ligature. 
This  can  only  be  avoided  by  tightening 
the  ligature  simultaneously  with  the 
loosening  of  the  clamp  or  removal  of  the 
forceps.  Mr.  Doran's  observations  lead 
him  to  the  conclusion  that  '  it  is  much 
more  dangerous  to  draw  the  ligatures  a 
little  too  firmly,  than  to  leave  them  some- 
what looser  than  is  strictly  advisable ;  * 
and  Mr.  Thornton  considers  the  presence 
of  blood-clot  on  the  cut  surface  of  the 
stump  '  as  the  pei'fect  condition  to  aim  at 
in  the  treatment   of  the  ovarian  pedicle 


92 


OVARIAX   AND   ALLIED   TUMOURS 


by  ligature.  This  cap  of  blood-clot  shows 
that  the  ligatures,  while  tight  enough  to 
prevent  serious  haemorrhage,  were  not  so 
tight  as  to  cut  off  all  supply  from  the 
distal  portion  of  the  stump.'  I  differ 
entirely  both  from  Mr.  Doran  and  Mr. 
Thornton,  and — fearing  that  a  loose  ligature 
will  become  looser  as  the  included  tissue 
shrinks,  that  bleeding  would  be  probable, 
and  that  unless  a  ligature  sinks  deeply 
into,  or  forms  a  deep  groove  in  the 
pedicle,  the  surfaces  of  peritoneum  on 
either  side  of  it  are  less  likely  to  unite, 
cover  up  the  silk,  and  maintain  the 
vitality  of  the  stump — I  alway.s  tie  the 
ligature  as  tightly  as  I  can. 

If  it  be  desired  only  to  tie  the  vessels, 
this  may  be  done  by  feeling  the  arteries, 
and    carrying    a    ligature    round    them 
through  the  pedicle  before  the  cyst  is  cut 
away  ;   or,  after  the  application  of  forceps 
and    removal    of    the    cyst,    holding    the 
pedicle    carefully   as  the  forceps  are  re- 
moved, and  tying  any  vessel  Avhich  bleeds. 
The  great  objection  to  this  plan  is,  that 
there  is  often  much  loo.se  cellular  tissue, 
rich  in  small  veins,  which  go  on  oozing 
after  all  the  larger  vessels  have  been  tied. 
Whichever  may  be  the  plan  preferred,  the 
important  question  arises :   Shall  the  ends  1 
of  the  ligatures  be  cut  off,  and  the  wound 
closed  ?  or  shall  they  be  left  hanging  out  | 
through  a  part  of  the  wound,   purposely 
left  open  for  their  passage,  and  that  of  the 
slough  they  embrace  when  it  separates? 
Dr.  Clay,  of  Manchester,  advocated  this 
latter  practice.     In  its  favour,  it  has  been 
taid,  that  it  is  a  method  applicable  in  all 
cases ;   that  it  secures  an  oiuiet  for  serum 
from  the  peritoneal  cavity  ;  and  that,  after 
the  separation  of  tlie  ligature  and  slough, 
no  foreign  body  is  left  within  the  patient. 
But  it   seems  to  me    that    the  ligature- 
threads  act  as  a  sort  of  seton  in  the  peri- 
toneal cavity,  excite  the  formation  of  the 
serum  for  which  they  are  said  to  provide 
the  outlet,  and  counteract  antiseptic  pre- 
cautions.      Having    tried    both    methods, 
the  results  very  soon  led  me  to  discontinue 
this  practice,  and  to  drain  by  a  glass  tut)e 
rather  than  by  the  ends  of  a  ligature.    On 
this  question  of  drainage  1  sliall  have  more 
to  say  hereafter.      One  objection  is,  that 
even  if  the  patient  recover,  there  is  a  great 
liability  to  ventral  hernia.     The  cicatrix 
remains  weak  at  the  spot  where  tlie  tube 
or  ligatures  passed  out,  and  it  yields  before 
the  pressure  outwards  of  the  viscera.      I 
have  seen  this  in  nearly  every  case  where 


I  adopted  this  plan. '  In  several  it  followed 
the  clamp,  and  in  some,  but  in  smaller 
proportion,  where  the  complete  intra-peri- 
toneal  method  was  practised,  and  I  have 
come  to  the  conclusion  that  if  we  use  one 
or  more  ligatures,  it  is  better  to  cut  off 
the  ends  short,  and  close  up  the  wound 
completely.  "Wire  has  been  used  for  the 
ligature,  but  it  seems  an  irrational  practice. 
Silk,  if  pure,  is  an  animal  substance  ;  and 
experiment  proves  that  it  may  be  ab- 
sorbed. Wire  cannot  be  absorbed,  and 
must  be  more  or  less  of  a  mechanical 
irritant.  I  tried  wire  on  one  side  and 
silk  on  the  other  side  of  a  sheep  on 
which  Professor  Gamgee  operated  ibr 
me,  and  the  superiority  of  the  silk  Avas 
manifest.  What  we  have  to  look  to  is 
the  effect  on  the  tissues  strangulated, 
rather  than  the  material  by  which  the 
strann'ulation  is  effected.  Catgut  has  been 
used,  but  I  know  of  nothing  to  show  that 
it  is  superior  to  carbolised  silk.  Professor 
Billroth  thinks  it  necessary  to  boil  the 
silk  in  a  5  per  cent,  solution  of  carbolic 
acid,  and  there  is  no  objection  to  do  this. 
His  results  certainly  improved  after  using 
boiled  silk. 

Supposing  there  is  no  true  pedicle — 
that  the  cyst  is  more  or  less  completely 
encapsuled  in  a  layer  of  broad  ligament, 
or  an  expansion  of  the  peritoneimi — this 
capstile  may  be  divided,  and  the  cyst  shelled 
out  of  it,  or  the  base  of  the  cyst  with  its 
enveloping  capsule  may  be  transfixed  and 
tied  in  two  or  more  portions  before  cyst 
and  covering  are  cut  away.  This  is  what 
many  operators  have  termed  a  very  short 
broad  pedicle.  In  some  cases  the  Fal- 
lopian tube,  more  or  less  elongated,  is  so 
closely  attached  to  the  capsule  that  it  is 
better  to  include  it  in  the  ligatures,  and 
cut  away  all  the  attached  part.  In  others 
it  is  imaltei-ed,  and  quite  iree  from  the 
capsule.  Then  it  is  better  not  to  interfere 
with  it.  The  ovary  also  may  be  either 
free  or  attached.  If  normal  and  free,  this 
also  is  better  left  undisturbed;  but  if 
closely  attached,  or,  as  it  sometimes  is, 
stretched  into  a  cordiike  or  flattened 
outer  layer  of  the  cyst  wall  and  capsule, 
its  removal  is  almost  inevitaVjle.  In  case 
of  doubt  it  is  better  to  remove  than  to 
leave  it,  even  if  separation  is  not  difli- 
cult. 

If,  after  enucleating  a  cyst,  any  con- 
sidcral)Ic  part  ot  the  capsule  remain,  and 
especially  if  any  oozingof  blcod  continties 
from  the  inner  surliice,  all  the  loose  part 


THE    OPERATION   OF   OVARIOTOMY 


93 


of  the  capsule  should  be  drawn  up,  its 
base  transfixed  and  tied,  and  tho  capsule 
cut  away.  In  the  very  rare  cases  where 
a  cyst  cannot  be  enucleated  from  the 
capsule  or  broad  ligament,  or  from  the 
retro-peritoneal  attachments,  we  must 
either  be  content  with  removing  the  fluid 
contents  and  closing  the  abdominal  cavity, 
or  employ  drainage.  The  choice  of  the 
two  methods  should  be  determined  by  the 
character  of  the  contents  of  the  cyst.  If 
clear,  watery  fluid  only,  the  safer  practice 
is  to  close  the  abdomen.  But  if  colloid, 
or  purulent,  or  dermoid,  drainage  is  cer- 
tainly the  preferable  practice. 

The    question,    what    becomes    of    a 
ligature,  and  of  the   tissues  strangulated 
by  it,  when  closed  up  in  the  peritoneal 
cavity,   is    a  very   important  one.     It  is 
certain    that   the    changes    differ   Avidely 
from  those  which  follow   the   use  of  the 
ligature  when  the  ends  are  left  to  pass  out 
through  the  partially  closed  wound.     In 
this  case  they  lead  to  free  discharge  of 
serum  or  pus,  until  the  separation  of  the 
ligature  and  the  slough.     Whatever  may 
be  the  material  of  the  ligature,  the  tissues 
strangulated  by    it   come   away   after   a 
process  of  suppuration  ;   and  if  anything 
like  what  goes  on  outside  the  body  when 
one  of   the   extra- peritoneal   methods  is 
adopted,  or  when  the  wound  is  left  open 
for  the  ligatures,  went  on  when  the  wound 
is   closed,  no   patient  could  survive  the 
process.     She  would  certainly  be  poisoned 
by  absorption  of  the  fetid  products  of  the 
decomposing   stump.      A   very   different 
series  of  changes  must  go  on  when  the 
wound  is  closed  and  access  of  air  shut  off. 
Experience   shows   that  patients  survive 
the  process;    and    examination  of  those 
who  have  died  has  shown  that  a  pedicle 
secured  by  a  silk  ligature  has  been  found 
some  days  afterwards,  either,    first,   sur- 
rounded by  coils  of  adhering   intestine ; 
second,  as  the  centre  of  a  purulent  cavity  ; 
third,  very  little  altered,  with  the  lisature 
deeply  imbedded  Avithin  it ;   and  fourth, 
completely  dead  or  gangrenous.     All  these 
different  conditions  I  have  actually  seen 
accompanied  by  more  or  less  evidence  of 
peritonitis,  and  depending  more,  I  believe, 
on  the  general  health  of  the  patient  and 
the  conditions  in  which  she  was  placed, 
than  upon  any  difference  in  the  material 
of  the  ligature  or  the  mode  of  its  applica- 
tion.    I   must  now,   of  course,  add  that 
among  the  conditions  in  which  the  patient 
is  placed,  we  attach  paramount  importance 


to  the  presence  or  absence  of  infective  or 
putrefying  mattei-. 

Our  knowledge  of  this  subject  has 
been  greatly  increased  by  the  report  of 
the  experiments  of  Spiegelberg  and  Wal- 
deyer.  Their  experiments  were  arranged 
in  two  series  :  1.  Excision  of  portions  of 
the  horns  of  the  uterus  of  bitches,  leaving 
the  ligatures  in  the  peritoneal  cavity; 
and  2.  Removal  of  portions  of  the  uterus 
by  the  galvanic  cautery.  The  conclusions 
of  the  experimenters  are  that  small  foreign 
bodies  may  be  left  in  the  peritoneal  cavity 
Avithout  danger,  and  that  strangulated  and 
cauterised  tissues  do  not  become  gan- 
grenous, and  are  not  injurious  to  neigh- 
laouring  parts,  provided  only  that  the 
abdominal  cavity  is  perfectly  closed. 

As  to  the  ligatures,  they  show  that  they 
are  absorbed  after  their  fibres  have  been 
separated  and  disintegrated  by  the  ingrowth 
of  cells  from  neighbouring  parts.  They 
are  generally  encapsuled,  but  may  some- 
times be  found  free  in  the  peritoneal 
cavity  or  in  cystic  cavities  of  ihe  stump. 
The  divided  surfaces  adhere  to  some  ad- 
jacent structures  and  form  vascular  com- 
munications without  any  trace  of  gangrene. 
New  cells  spring  up  from  the  tissues  around 
and  unite  with  the  granulations  of  the  cut 
surfaces.  There  is  no  trace  of  gangrene 
in  the  ligatured  part,  and  new  cell  forma- 
tions enclose  the  ligature. 

The  vessels  of  cauterised  parts  are 
blocked  by  clot,  and  the  dead  tissue  is  en- 
capsuled  by  growth  of  new  cells.  In  14 
or  21  days  the  cauterised  surfaces  are 
covered  over  by  new  tissue  formed  from 
the  cells  supplied  by  the  surrounding 
structures. 

Maslowsky  corroborated  the  observa- 
tions of  the  German  experimenters,  and 
showed  that  the  eschar  from  cauterisation 
is  first  covered  by  effused  fibrine,  and 
afterwards  united  by  membrane  with  sur- 
rounding organs.  The  white  corpuscles 
participate  in  the  formation  of  the  new 
membrane,  in  which  capillaries  may  be 
found  as  soon  as  the  4th  or  5th  day. 

In  some  respects  the  experiments  are 
satisfactory,  as  they  tell  us  what  really  does 
take  place  when  a  ligature  or  an  eschar 
is  shut  up  in  the  peritoneal  cavity ;  and 
we  may  resort  to  the  cautery  or  the 
ligature  with  a  pretty  accurate  idea  of  the 
process  of  repair  and  of  the  dangers  which 
may  attend  this  process. 

Doran,  in  two  papers  in  the  loth 
and  14:th  volumes  of  '  St,  Bartholomew's 


94 


OVARIAN   AND  ALLIED   TUMOURS 


Hospital  Reports,'  gives  the  results  of 
his  own  observations  of  10  cases  where 
he  examined  the  ligature  and  pedicle  at 
various  periods  after  ovariotomy  ;  all 
proving  that  the  tied  or  strangulated 
stump  is  not  killed,  but  that  '  a  communi- 
cation between  the  distal  and  proximal 
parts  of  the  stump  is  established  by  in- 
flammatory plastic  effusion,  and  the  liga- 
ture is  unravelled  by  granulation-cells 
insinuating  themselves  between  its  fibres.' 
He  also  shows  that  the  distal  part  of  the 
stump  may  soon  form  an  intimate  adhesion 
with  the  neighbouring  broad  ligament. 

It  must  not  be  forgotten  that  even 
in  healthy  dogs  and  rabbits  Avhere  the 
ligature  or  the  cautery  was  considered  by 
the  German  experimenters  to  have  been 
most  successful,  adhesion  of  the  tied  or 
cauterised  part  to  the  bladder,  to  intestine, 
and  to  neighbouring  folds  of  peritoneum, 
has  been  the  rule,  just  as  in  cases  which  I 
have  placed  upon  record  where  adhesion 
of  the  tied  or  cauterised  pedicle  to  intes- 
tines has  led  to  fatal  strangulation.  Even 
if  not  fatal,  such  adhesions  are  more  likely 
to  lead  to  obstruction  of  intestine  more 
or  less  serious  and  prolonged,  and  to  be 
permanently  injurious,  than  the  mere 
adhesion  of  a  pedicle  to  the  abdominal 
wall. 

Acupressure  was  once  applied  success- 
fully by  Sir  James  Simpson.  He  secured 
the  pedicle  by  passing  a  long  needle 
through  the  abdominal  wall,  across  the 
pedicle,  and  out  again.  The  pedicle  was 
thus  compressed  by  the  needle  on  the 
outside  of  the  abdominal  wall  in  the  left 
iliac  region. 

Sir  William  Fergusson  once  tried  this 
plan,  but  was  obliged  to  resort  to  the 
ligature.  I  have  never  tried  it  myself, 
though  I  have  more  than  once  found 
acupressure  useful  in  stopping  bleeding 
from  vessels  torn  in  separating  adhesions. 

The  ecraseur  has  been  used  for  the 
compression  and  crushing  of  the  pedicle 
and  separation  of  the  tumour ;  after  which 
the  pedicle  is  dropped  into  the  abdominal 
cavity  and  the  wound  closed.  Grave 
objections,  however,  against  this  practice 
are  the  possibility  of  hfemorrhage  and  its 
dangers,  and  the  difTiculty  of  finding  and 
securing  the  bleeding  pedicle  in  the  depth 
of  the  abdominal  cavity  after  having  re- 
opened the  wound.  This  would  be 
especially  difficult  if  haemorrhage  occurred 
after  some  lapse  of  time.  I  once  used  the 
Ecraseur  and  successfully  ;  but  I  have  not 


ventured  on  it  again,  for  fear  that  bleeding 
might  occur.  This  danger  might  be  pre- 
vented by  tying  a  ligature  below  the 
ecraseur  chain,  before  separating  the  cyst 
and  dropping  the  pedicle  into  the  abdomi- 
nal cavity.  But  then  it  would  be  only  a 
modification  of  other  methods  of  liga- 
tures. 

The  cauterji  alone  Avould  fail  to  stop 
such  large  vessels  as  are  fi'equently  met 
with  in  a  pedicle.  So  might  the  crushing 
which  precedes  the  division  by  the  ecraseur. 
But  the  comhinalion  of  crushimj  and  the 
cauterji  is  certainly  efficacious  in  a  con- 
siderable proportion  of  cases.  Clay,  of 
Birmingham,  introduced  the  practice  and 
carried  it  out  by  his  adhesion  clamp  and 
hot  irons,  both  for  dividing  adhesions  and 
omentum.  The  practice  was  extended  to 
the  pedicle  by  Baker  Brown,  and  has 
since  been  used  chiefly  by  Keith.  It  is 
claimed  for  it  that  in  most  cases  it  effec- 
tually stops  hsemorrhage  during  the  opera- 
tion and  prevents  it  afterwards,  that  it 
leaves  only  a  very  thin  layer  of  burnt 
tissue  at  the  end,  and  is  followed  only 
by  the  changes  described  in  a  former 
page.  This  method  is  of  most  value  in 
cases  when  the  pedicle  is  broad,  thick,  and 
short ;  it  does  not  answer  well  when  large 
vessels  ramify  in  a  thin  membranous 
pedicle.  Notwithstanding  the  great  ad- 
vantage of  the  cautery,  its  use  is  attended 
by  serious  drawbacks.  Vessels  not  un- 
frequently  bleed  on  opening  the  blades  of 
the  clamp,  and  a  repetition  of  the  whole 
tedious  proceeding,  or  the  use  of  ligatures, 
is  necessary  before  the  pedicle  can  be 
returned  into  the  abdomen  with  safety. 
The  instrument  used  for  compressing  the 
pedicle  and  various  cauteries,  with  the 
mode  of  using  them,  have  been  described 
in  the  last  chapter. 

When  dividing  the  pedicle  and  sepa- 
rating the  cyst,  the  utmost  care  must  be 
taken  to  prevent  any  of  the  contents 
entering  the  abdominal  cavity.  Shtmld 
this  happen  notwithstanding  all  the  pre- 
cautions taken  to  avoid  it,  the  cavity 
must  be  carefully  sponged  and  cleaned  of 
all  extraneous  substance  with  soft  sponges 
wrung  out  of  Avarm  carbolised  water. 

The  omentum,  the  mesentery,  and  the 
situations  of  the  adhesions  to  the  anterior 
abdominal  wall  will  often  be  found  the 
seat  of  haemorrhage,  either  from  the 
orifices  of  large  vessels  or  from  capillary 
oozing.  The  bleeding  must  be  stopped 
by   tying  the  vessels  with   ligatures,  the 


THE   OPERATION   OF   OVAEIOTOMY 


95 


ends  of  which  are  to  be  cut  off  close  to 
the  knot,  or  by  toi-sion,  or  by  the  pressure 
of  a  needle  passed  across. 

The  following  table  shows  the  results 
o£  my  own  trials  of  various  modes  of 
dealing  with  the  pedicle  in  1,000  cases : 


o 

.a 

3  o 

497 

126 

P,  ^ 

Clamp  .... 

623 

20-22 

Tin  and  ligature  acting 

as  clamp  . 

17 

11 

6 

8.5-23 

Clamp  and  ligature 

49 

.-54 

15 

30-61 

Ligature  returned 

260 

191 

69 

26-53 

Ligature  brought  out  . 

14 

6 

8 

,57-14 

Cautery 

16 

14 

2 

12-5 

(Cautery  and  ligature  . 

14 

10 

4 

28-57 

]''craseur  and  pin 

2 

2 

0 

0 

Forceps  and  ligature    . 

1 

0 

1 

100 

No    ligature — enuclea- 

tion .... 

o 

3 

0 

0 

Cyst     wall     sewed    to 

abdominal  wall 

1 

1,000 

0 

1 

100 

768 

232 

23-2 

As  soon  as  the  pedicle  has  been 
secured,  the  tumour  removed,  and  bleed- 
ing vessels  have  been  tied,  the  other  ovary 
should  be  examined.  It  is  found  by 
grasping  the  fundus  of  the  uterus,  and 
passing  the  hand  downwards  along  the 
tube  and  side  of  the  uterus.  The  sur- 
face may  be  irregular  from  recently 
matured  follicles,  but  these  need  not  lead 
to  interference  unless  the  ovary  is  two  or 
three  times  its  normal  size.  If  any 
follicles  are  very  large,  they  may  be 
punctured,  and  the  clot  they  contain 
squeezed  out.  If  the  ovary  is  hardened 
or  enlarged,  it  should  be  removed.  When 
the  clamp  was  used  the  pedicle  has  some- 
times been  long  enough  to  admit  of  the 
application  of  two  clamps  outside  the 
abdominal  wall  with  little  more  incon- 
venience to  the  patient  than  one.  In 
other  cases  I  have  transfixed  the  pedicle 
of  the  second  tumour,  tied  it  in  two  or 
more  portions,  brought  it  outside,  and 
tied  it  to  the  clamp  securing  the  first 
pedicle.  Recently  I  have  always  tied 
bfith  pedicles  with  silk,  cutting  off  the 
eiids  short,  just  as  when  only  one  ovary 
has  been  removed. 

Besides  examining  the  second  ovary, 
the  state  of  the  uterus  should  be  ascer- 
tained. It  may  be  enlarged  by  pregnancy, 
or  by  fibroid  growths.  In  one  case,  after 
completing  ovariotomy,  I  also  removed  a 
fibroid  outgrowth  ii-om  the  fundus  uteri. 
This  patient  died,  and  I  think  she  would 


have  recovered  if  I  had  left  the  uterus 
alone,  as  I  have  done  in  several  cases 
since,  where  the  size  of  the  growths  was 
insignificant.  But  when  they  have  been 
large  enough  to  cause  much  inconveni- 
ence, I  have  removed  them  at  the  same 
time  as  the  ovarian  tumour.  In  one  case 
the  patient  recovered  after  removal  of  a 
uterine  tumour  nearly  as  large  as  the 
ovarian,  and  from  another  I  successfully 
removed  a  dermoid  cyst  of  the  left  ovary, 
and  a  fibroid  outgrowth  from  tlie  right 
side  of  the  uterus  at  the  one  operation. 

SPONGING    OF    THE    PERITONEUM 

Before  proceeding  to  close  the  wound, 
the  peritoneal  cavity  must  be  thoroughly 
cleansed  from  any  iluid  or  clot  which  it 
may  contain.  A  good  deal  of  Iluid  may 
be  pressed  out,  or  scooped  out  by  the 
hand ;  but  complete  cleansing  can  only 
be  attained  by  using  many  clean,  soft 
sponges  in  succession,  passing  them  well 
down  behind  and  in  front  of  the  uterus, 
along  each  flank  in  front  of  the  kidneys, 
and  over  the  abdominal  wall  wherever 
adhesions  have  been  separated.  Any 
clot  which  may  be  seen  or  felt  among  the 
coils  of  intestine  or  folds  of  omentum 
must  be  removed.  When  I  began  to 
insist  upon  the  importance  of  this  process, 
Avhicli  Worms  described  as  la  toilette  du 
pe'ritoinc,  other  operators  said  that  it  was 
unnecessary  or  injurious  ;  that  ovarian 
fluid  in  the  peritoneum  was  harmless ;  or 
that  the  time  lost  in  removing  it,  and  the 
in-itation  caused  by  the  sponging,  Avere 
greater  evils  than  a  little  fluid  or  blood 
left  in  the  cavity.  Impressed  by  these 
objections,  I  was  in  one  case  less  careful 
than  usual  in  sponging  away  ovarian  fluid. 
A  fatal  result  followed,  and  I  have  ever 
since  been  extremely  careful  to  remove 
all  by  thorough  sponging,  and  have  been 
Avell  satisfied  with  the  results.  I  have 
regretted  incomplete  sponging,  never  that 
I  had  been  too  careful.  And  it  is  con- 
venient to  insert  a  large,  flat  jjiece  of 
sponge  just  within  the  wound,  and  leave 
it  all  the  time  that  the  sutures  are  being 
passed.  It  catches  any  drops  of  blood 
Avhich  may  follow  the  j^assage  of  the 
needles,  and  if  spray  be  used  protects  the 
cavity  from  the  cooling  eff'tjct  of  the  spray 
or  the  entrance  of  carbolic  acid. 

CLOSURE    OF    THE    WOUND 

The  next  step  will  be  to  close  the 
wound.     In  my  early  cases  I  did  this  by 


96 


OVArJAX   AND   ALLIED   TUMOURS 


passing  hare-lip  pins  through  the  whole 
thickness  of  the  abdominal  wall  at  inter- 
vals of  an  inch.  Each  pin  perforated  the 
skin  about  an  inch,  and  the  peritoneum 
about  half  an  inch,  from  the  incision  on 
either  side ;  so  that  when  the  two  op- 
posed surfaces  were  pressed  together  upon 
the  pin,  two  layers  of  the  peritoneum 
were  in  contact  with  each  other.  But  I 
soon  began  to  prefer  sutures  to  pins,  and 
tried  different  materials  for  this  purpose. 
After  repeated  trials  I  found  thin  strong 
Chinese  silk  superior  to  other  materials 
ibr  closing  the  wound,  as  I  had  for  tying 
the  pedicle.  For  some  years  I  have 
soaked  the  silk  in  a  5  per  cent,  solution 
of  carbolic  acid  before  using  it,  and  Bill- 
roth's  experience  proves  that  it  may  be 
safer  to  boil  the  silk. 


The  most  convenient  manner  of  ap- 
plying the  sutures  is  the  following  :  Silk 
about  eighteen  inches  in  length  is  threaded 
at  each  end  on  a  strong  straight  needle. 
Each  needle  is  introduced  by  a  holder 
from  within  outwards,  through  the  peri- 
toneum and  the  whole  thickness  of  the 
abdominal  wall,  at  about  one-third  of  an 
inch  from  the  cut  edges  of  peritoneum 
and  skin  on  either  side  —  pinching  up 
peritoneum  and  skin  together,  so  that  the 
silk  may  be  carried  through  both  without 
perforation  of  the  recti  muscles.  The 
ends  of  the  sutures  are  held  by  the  assist- 
ant, who  draws  up  the  lips  of  the  wound 
until  all  the  deep  sutures  have  beea 
applied.  Then  the  lips  of  the  wound 
are  held  apart  again,  in  order  that  the 
operator    may   convince  himself  that  no 


further  bleeding  has  taken  place  within 
the  abdominal  cavity,  which,  if  required, 
has  to  be  sponged  again,  and  the  protect- 
ing sponge  removed.  Tliis  done,  the 
sutures  are  tied,  carefully  adapting  the 
edges  of  the  skin  to  each  other  with<nit 
inversion  or  eversion,  and  the  ends  of  the 
threads  are  cut  off.  If  the  abdominal  wall 
is  very  thick,  superficial  sutures  may  be 
required  between  the  deep  ones.  If  the 
pedicle  has  been  secured  by  the  clamp,  a 
suture  should  be  passed  close  to  the  latter, 
in  order  to  bring  the  lips  of  the  Avound 
so  accurately  around  the  pedicle  that  the 
peritoneal  cavity  is  perfectly  closed. 

DKESSING    AND    BANDAGE 

After  the  closure   of  the  wound,  the 
abdomen  is   carefully  cleaned  and  dried, 


the  india-rubber  cloth  removed,  and  the 
woimd  covered  with  some  non-irritatin" 
antiseptic  gauze,  or  salicylic  or  boracic 
wool,  and  supported  by  long  strips  of 
adhesive  plaster.  In  many  cases  the  false 
ribs  have  been  pressed  outwards  by  the 
tumour,  and  after  its  removal  a  'deep 
hollow  is  left.  This  must  be  filled  up 
with  puds  of  cotton-wool.  A  flannel  belt 
is  fastened  around  her  abdomen  by  pins, 
and  the  patient  is  then  gently  removed  to 
her  bed.  She  is  kept  on  her  back,  her 
knees  supported  by  a  pillow,  is  covered 
with  light  but  warm  blankets,  and  pro- 
vided Avith  hot-water  bottles,  if  .she  is  at 
all  chilly.  Tlie  room  is  darkened,  and  she 
is  left  alone  witli  her  nurse.  After  ovari- 
otomy and  other  serious  operations,  pa- 
tients rally  much  more  rapidly  if  the  head 
be  kept  wa-m,  covered  up  with  a  shawl  or 


ACCIDENTS   DURING  OVARIOTOMY 


97 


flannel.  "When  we  reflect  how  tempera-  |  is  well  established  may  be  very  advan- 
ture  is  lowered  by  cooling  the  head,  it  tageous.  If  reaction  is  slow,  the  head 
is  not  difhcult  to  understand  that  warm-  should  not  be  raised  by  pillows,  but  kept 
ing  the    head  until   reaction  after  shock  I  low. 


CHAPTER  VIII 


ACCIDENTS   DURING    OVARIOTOJIY 


Fainting  is  an  accident  which  may  happen 
in  any  operation,  and  before  the  use  of 
aniEsthetics  was  not  uncommon,  I  have, 
however,  never  been  embarrassed  in  my 
ovariotomies  by  this  condition.  And 
only  in  one  case  has  the  methylene 
caused  any  trouble.  Then  the  pulse 
became  for  a  while  imperceptible,  and 
we  Avere  obliged  to  give  brandy.  The 
woman  rallied.  She  had  some  thoracic 
complication,  and  though  the  cyst  only 
contained  about  16  pints  of  fluid,  yet,  as 
the  removal  was  very  quickly  over,  it  is 
possible  that  the  enfeebled  heart  and 
lungs  were  unable  to  accommodate  them- 
selves to  the  sudden  change  of  pressure. 

Out  of  the  127  deaths  which  followed 
my  first  500  operations,  20  were  put 
down  as  the  effect  of  exhaustion,  and 
none  from  haemorrhage  ;  while  in  the 
second  series  of  105  deaths  there  were 
only  8  from  exhaustion  and  2  from 
haemorrhage.  The  probability  is  that 
some  of  the  first  series  of  deaths  were 
also  partly  due  to  bleeding,  but  the  fact 
was  not  established  by  examination.  The 
deaths  from  exhaustion  were  mostly  at 
the  end  of  2  or  3  days,  but  in  1  as  early 
as  13  hoars.  No  case  of  collapse  after 
the  operation  happened  in  the  second 
series,  but  in  the  first  there  were  6  cases 
— the  time  being  fi:om  2  hours  to  about 
40  hours.  No  death  has  ever  occurred 
during  the  operation  either  from  shock 
alone  or  the  anaesthetic. 

Thus  out  of  the  232  deaths  after 
1,000  operations  only  36  are  immediately 
attributable  to  shock  and  ha3morrhage, 
a  proportion  lessened  by  increased  ex- 
perience. The  remaining  mortality  o£ 
196  w;is  due  to  other  causes;  and,  con- 
sidering  the  large  proportion  of  septic 
disease  which  proved  fatal  during  the 
earlier  years,  was  to  a  great  extent 
avoidable.  The  mortality  of  3'6  per 
cent,   from  shock   and  hemorrhage  cor- 


responds very  nearly  with  the  results  of 
Keith's  practice,  in  which  there  are  very 
few  deaths  recorded  as  from  secondary 
causes ;  while  in  my  own  experience  in 
private  cases  and  since  adopting  Listerian 
details,  I  have  had  only  3  immediate 
deaths,  2  from  cardiac  embolism  in  about 
20  hours,  and  one  from  hgemorrhage 
almost  immediately  after  the  patient  was 
in  bed.  But  this  was  not  a  case  of  ovari- 
otomy only.  It  occurred  since  the  com- 
pletion of  the  1,000  cases,  and  I  unwisely, 
after  removing  an  ovarian  tumour,  at- 
tempted to  remove  a  cyst  of  the  liver. 
In  one  case  of  secondary  bleeding  which 
came  on  shortly  after  the  operation  was 
finished,  I  reopened  the  wound,  put 
another  ligature  on  the  pedicle  in  lieu  of 
the  one  which  had  slipped,  and  left  the 
patient  not  the  worse  for  the  accident.  She 
got  rapidly  well.  In  another  case  I  feared 
that  the  patient  was  dying  of  internal 
bleeding,  but  the  father  and  brother,  both 
medical  men,  were  opposed  to  the  reopen- 
ing of  the  wound,  and  would  not  permit 
an  examination  after  death,  so  that  I  am 
not  quite  sure  how  far  my  fear  was  well 
founded.  In  1882  secondary  bleeding 
occurred  a  few  hours  after  operation  on  a 
lady  aged  62.  I  opened  the  wound,  found 
that  the  ligature  had  slipped,  transfixed 
and  tied  the  pedicle,  sponged  out  the 
peritoneal  cavity,  and  reclosed  the  wound 
— assisted  by  Mr.  Fuller  of  Piccadilly. 
The  patient  did  not  seem  much  the  worse 
for  the  accident,  but  she  died  on  the  5tli 
day. 

Burst  cysts  and  suppurating  cysts  do 
not  seem  to  have  lowered  the  success  of 
my  operations.  There  have  been  15  such 
cases,  12  burst  cysts  and  3  sup[)urating 
cysts,  among  my  1,000  operations,  and 
only  1  death  resulted.  My  experience 
of  139  cases  since  the  1,000  gives  6  cases 
where  the  cysts  had  burst ;  of  these  3  re- 
covered and  3  died. 


98 


OVARIAN  AND   ALLIED   TUMOUES 


Injuries  to  viscera. — Several  cases  are 
on  record,  and  I  have  heard  of  others  not 
recorded,   where   the   bladder   has    been 
injured    either    in    making    the    first  in- 
cision or  in  separating  adhesions  between 
the  cyst  and    the    bladder.     Should    the 
bladder  be   injured,  the  opening  should 
be  very  carefully  closed  by  suture,  and  a 
catheter    maintained    in    the   bladder  for 
several  days.     As  a  rule  the  effects  Imve 
not  been  serious,  although  in   some  cases 
the  urine  has  drained  through  the  wound 
for  several  days.     In  one  case  where  I 
had  cut  into  a  patent  urachus  from  which 
urine  escaped,   I  closed  the   opening  by 
one  of  the  sutures  which  closed  the  in- 
cision in    the    abdominal    wall,    and    no 
inconvenience    followed.      In    1881  Pro- 
fessor Billroth,  in  making  a  double  ovario- 
tomy, was  obliged  to  resect  part  of  the 
bladder  and  some  inches  of  small  intestine 
on  account    of  adhesions  between  these 
parts.  And  in  another  double  ovai-iotomy, 
done  at  the  Salp^triere  by  Professor  Pozzi 
in  December  1882,  though  all  due  precau- 
tions had  been  taken  to  empty  the  bladder, 
there  was  found,  after  opening  the  peri- 
toneum, a  layer  of  what  appeared  to  be  a 
membranous   expansion,  the   product  of 
Bome  old  inflammation.     An  incision  of 
at    least    10    centimetres,   corresponding 
with  that  in  the  peritoneum,   was  made 
through  this.     After  removing  the    two 
ovaries,  and  when  preparing  to  close  the 
abdominal   wound,  the    supposed  mem- 
brane, on  being  examined,  proved  to  be 
the    bladder.     It   had   in   no   way    con- 
tracted after  the  use  of  the  catheter,  and 
the  hand  could  be  easily  passed  into  it 
through  the  wound.     Professor  Pozzi  had 
therefore  to  deal  with  a  wound  of  both  the 
anterior  and  posterior  coats.  The  posterior 
one    he    closed   completely  with   sutures. 
That  in  front  was  partially  sewn  up,  and 
the  opening  left  was  made  to  correspond 
exactly     with     a    part    of    that     in   the 
aV)dominal    wall.      A    siphon-tube     was 
arranged  to   drain  away   the  urine,  and 
the    bladder   was,    from    time    to    time, 
washed  out   with  a  solution   of   boracic 
acid.     By  the  end  of  January  the  urine 
began   to  pass  naturally  ;    in  March  the 
fistula  Avas  closed,  and  the  woman  entirely 
recovered. 

The  rectum  has  been  torn  or  divided 
(luring  the  separation  of  adhesions,  in  some 
cases  with  fatal  consequences  ;  in  otliers, 
where  accurate  closing  has  been  efrected 
by  suture,  recovery  has  followed  without 


any  ffecal  fistula.     In  a  patient  on  whom 
I  operated    in   July    1876,  removing    a 
tumour  of  the  right  ovary,  the  left  having 
been  removed   3  years  before,  the   cyst 
was  drawn  out  with   a  coil  of  adherent 
intestine.     This  was  carefully  separated, 
but  not  without  a  tear,  leaving  an  open- 
ing sufficiently  large  to  admit  one  finger, 
I  inverted  the  edges  of  the  opening  so  as 
to  bring  two  surfaces  of  the  peritoneum 
in  apposition,  united  them  by  a  continuous 
silk    suture,    and   the    patient   recovered 
without  any  ill  effect  from  the  accident. 
In    another    case     operated    on    in    the 
Samaritan  Hospital  in  June  1875,  in  re- 
moving   a    malignant    growth    weighing 
41  poiuids,  I  also  detached  and  cut  away 
about  3  inches  of  small  intestine,  the  coats 
of  which  were  involved  in  the   disease. 
The  upper  and  lower  ends  of  the  gut  were 
brought  together  and  united  by  peritoneal 
suture,  but  the  patient  died  on  the  11th 
day.       Although    some    fa2cal    fluid    had 
escaped  from  the  wound  in  the  abdominal 
wall,  the   bowels  had   acted   freely  in  a 
natural  manner,  and  it  appeared  that  the 
wound  in  the  intestine  had  but  little  to 
do  with  the  fatal  result.     The   practical 
lesson  from  this  is  to  be  extremely  careful 
when    separating  adhesions   between   the 
cyst  and  intestine,  and  if  the  intestine  is 
either  accidentally  wounded,  or  a  diseased 
portion    is    intentionally    removed,    the 
union   of    the    peritoneal  edges   by  fine 
sutures   must   be   very   accurately  com- 
pleted. 

The  liver  has  been  injured  during  the 
separation  of  adhesions.  In  one  case,  in 
an  insane  patient  under  the  care  of  Mr. 
Archer,  of  St.  John's  Wood,  I  removed 
some  ounces  of  the  lower  edge  and  under 
surface  of  both  lobes  of  a  large  liver.  I 
had  considerable  trouble  in  stopping  the 
bleeding,  and  applied  perchloride  of  iron 
freely.  The  ovarian  cyst  for  which  I  was 
operating  was  a  very  large  one,  and  the 
patient  in  an  extremely  feeble  condition 
after  repeated  tappings,  yet  she  recovered 
rapidly  and  completely  as  in  the  most 
simple  case,  is  still  alive,  and  has  regained 
her  soundness  of  mind  as  well  as  body. 
In  one  other  case,  already  alluded  to,  I 
lost  a  patient  from  hajmorrhage  after 
opening  a  cyst  which  projected  from  the 
under  surface  of  the  liver,  tl:e  walls  of 
which  poured  out  blood  with  extreme 
rapidity  in  spite  of  all  efforts  to  check  it. 
I  have  never  met  with  a  case  in 
which  the  spleen  has  been  injured  during 


ACCIDENTS   DURING   OVARIOTOMY 


99 


ovariotomy ;  but  an  enlarged  spleen  has 
been  occasionally  mistaken  for  an  ovarian 
tumour,  and  splenic  cysts  mistaken  for 
ovarian  cysts  have  been  removed  more 
than  once.  Should  either  of  these  mis- 
takes be  recognised  after  beginning  an 
operation,  the  surgeon  must  act  exactly 
as  if  he  were  doing  splenotomy. 

If  a  kidney  should  be  unavoidably  or 
accidentally  removed  with,  or  instead  of, 
an  ovarian  tumour,  as  much  care  would 
be  called  for  in  securing  the  blood-vessels 
as  in  a  case  of  nephrectomy  planned  be- 
forehand. One  or  both  ureters  are  known 
to  have  been  divided  or  tied  accidentally. 
In  Simon's  famous  case,  where  a  urinary 
fistula  remained  after  injury  to  the  right 
ureter,  Simon  removed  the  right  kidney, 
and  I  saw  the  Avoman  some  months  after- 
wards in  excellent  health.  In  a  similar 
case  Nussbaum,  instead  of  removing  the 
kidney,  re-established  communication  be- 
tween the  kidney  and  the  bladder.  It  is 
remarkable  that  in  cases  of  adhesions  low 
down  in  the  pelvis  the  ureters  should 
escape  injury  so  often  as  they  do.  I  sus- 
pect that  their  condition  has  been  over- 
looked in  some  post-mortem  examina- 
tions, and  it  is  probable  that  in  some  of 
the  cases  where  suppression  of  urine  has 
been  a  prominent  symptom,  one  or  both 
ureters  may  have  been  injured.  I  have 
heard  of  one  case  where  after  death  one 
ureter  was  found  tied. 

After  passing  the  sutures  which  are  to 
close  the  opening  in  the  abdominal  wall, 
and  before  tying  them,  the  sponges  and 
forceps  should  be  counted.  It  is  a  good 
plan  to  take  a  fixed  number  of  sponges 
and  forceps  to  every  operation.  By  for- 
ceps I  mean  the  torsion  or  pressure-for- 
ceps, the  use  of  which  has  been  already 
described.  Of  these  I  always  take  12,  of 
sponges  20.  If  any  other  than  the  usual 
fixed  number  be  taken,  some  doubt  is  al- 
most certain  to  arise  when  the  nurse  is 
told  to  count  the  sponges.  Very  small 
sponges  are  so  easily  lost,  that  it  is  ad- 
visable not  to  use  any  which  when  wet 
are  smaller  than  an  ordinary  fist.  Even 
then  it  may  not  be  easy  to  find  one  when 
wet  in  the  peritoneal  cavity.  It  is  a  good 
rule  for  the  surgeon  strictly  to  forbid  either 
of  his  assistants  to  put  a  sponge  within 
the  abdominal  cavity.  JMo  one  should  be 
allowed  to  divide  a  sponge.  One  of  my 
f;-iends  abroad  writes  that  in  one  of  his 
i'atal  cases  a  sponge  was  found  in  the  peri- 
toneal cavity.     He  had  suspected  that  a 


sponge  might  be  within  the  abdomen  at 
the  end  of  the  operation,  but  could  not 
find  it,  and  on  counting  the  sponges  the 
number  was  complete.  It  afterwards  ap- 
peared that  one  had  been  torn  into  two 
by  one  of  the  nurses.  No  one  who  has 
not  tried  it  can  understand  how  difficult 
it  may  be  sometimes  to  find  a  lost  sponge. 
In  my  lectures  as  Hunterian  Professor 
at  the  Royal  College  of  Surgeons  in  June 
1878,  I  gave  the  following  account  of  a 
case  in  which  I  left  a  pair  of  forceps  in 
the  abdomen.  'Not  very  long  ago  I 
removed  both  ovaries,  and  a  great  many 
forceps  were  used.  After  removing  one 
ovary  and  securing  the  pedicle,  the  other 
ovary  had  to  be  removed.  It  had  a  very 
short  pedicle,  and  5  or  G  of  my  torsion- 
forceps  were  put  on  in  order  to  secure  the 
bleeding  vessels,  while  I  was  tying  them 
separately.  I  took  off,  as  I  thought,  every 
pair  of  forceps,  closed  the  wound,  and 
everything  seemed  quite  as  it  should  be. 
But  about  2  hours  after  the  operation 
I  received  a  message  from  a  friend  who 
was  putting  up  the  instruments  for  me,  to 
say  there  was  a  pair  of  forceps  missing. 
We  knew  exactly  the  number  of  forceps. 
If  we  had  not  known  that,  one  pair 
would  not  have  been  missed.  This  shows 
how  necessary  it  is  always  to  know  how 
many  forceps  are  taken.  It  was  about  5 
in  the  afternoon  when  I  had  this  message  : 
'  There  was  a  pair  of  forceps  missing,  pro- 
bably they  might  be  in  the  patient.'  Ima- 
gine the  sort  of  feeling  with  which  one 
would  receive  that  intimation.  I  at  once 
went  to  the  patient.  She  seemed  so  well 
that  I  did  not  like  to  disturb  her.  There 
was  some  doubt  where  the  forceps  might 
be,  so  I  thought  I  would  wait  a  little 
longer.  I  waited  till  night;  she  still 
seemed  pretty  well,  and  I  thought  I  would 
wait  till  the  morning ;  but  in  the  morning 
the  nurse  told  me  the  lady  had  been  very 
restless.  I  then  made  a  very  careful 
examination,  by  the  vagina,  and  rectum, 
and  abdominal  wall,  to  see  if  I  could  feel 
the  forceps,  but  there  was  nothing  to  be 
felt  at  all.  Still  I  was  uneasy,  and  I 
thought  I  had  better  open  the  wound. 
So  I  gave  her  methylene,  removed  the 
dressing,  and  took  oat  two  stitches.  I 
put  one  finger  in,  but  at  first  could  not 
feel  the  forceps.  At  last  I  found  some- 
thing hard,  put  another  finger  in,  and 
found  the  forceps  wrapjDed  up  in  the 
omentum.  From  the  way  in  which  the 
omentum    had   insinuated  itself  into  the 

H  2 


100 


OVARIAN   AND   ALLIED  TUMOURS 


ring  handles  of  the  forceps,  it  was  easy  to 
understand  how  difficult  it  was  to  find 
and  remove  the  instrument ;  but  I  did  it, 
returned  the  omentum,  closed  the  wound, 
and  the  patient  was  none  the  worse.  She 
got  well,  and  to  this  day  does  not  know 
that  anything  unusual  occurred.' 

I  purposely  avoid  relating  a  case  where 
a  pair  of  forceps  was  found  in  the  bladder 
of  a  patient  a  month  after  recovery  from 
ovariotomy,  as  the  occurrence  is  still  to  me 
inexplicable.  It  did  impress  upon  me,  how- 
ever, what  I  had  often  before  told  others, 
that  the  surgeon  should  take  all  the  instru- 
ments and  sponges — not  allow  assistants  or 
nurses  to   supply    either — and   never   to 


neglect  counting  both.  I  ought  to  have 
added  that  this  should  be  done  before 
closing  the  wound,  and  thus  avoid  such 
an  unpleasant  accident  as  happened  to  me 
last  year  in  a  case,  where  I  was  operating 
without  either  of  my  usual  assistants. 
The  patient  was  in  bed  before  the  forceps 
were  counted.  One  pair  was  missed  before 
she  had  quite  recovered  from  the  anass- 
thetic;  a  little  more  was  given.  I  took 
out  two  stitches,  and  found  the  forceps 
without  much  difficulty.  The  patient 
made  a  good  recovery.  I  repeat  the  cau- 
tion, always  to  count  both  sponges  and 
forceps  before  closing  the  opening  in  the 
abdominal  wall. 


CHAPTER  IX 


ON    THE    REMOVAL    OF    BOTH    OVARIES    AT    ONE    GPEt^ATION 


Some  writers  on  ovarian  disease  have 
asserted  that  the  right  ovary  is  much 
more  frequently  diseased  than  the  left, 
and  that  coexisting  disease  of  both  ovaries 
is  extremely  rare.  But,  on  examining 
the  grounds  for  these  assertions,  we  find 
that  they  are  principally  based  upon 
examination  of  patients  during  life,  or 
patients  who  have  not  been  submitted  to 
ovariotomy. 

When  we  come  to  examine  the  result 
of  post-mortem  examinations  we  find  that, 
as  there  is  no  anatomical  or  physiological 
reason  why  the  right  ovary  should  be 
more  frequently  affected  than  the  left,  so, 
in  fact,  one  ovary  is  found  to  be  diseased 
as  oilen  as  the  other. 

Of  80  cases  collected  by  West  from 
Scanzoni,  Lee,  and  his  own  notes  of 
post-mortem  examitiations,  in  28  the 
disease  was  on  the  right  side,  in  26  on  the 
left  side,  and  in  26  both  ovaries  were 
diseased — so  that  in  about  one-third  of 
the  cases  both  ovaries  were  diseased.  In 
186.")  Scanzoni  again  drew  attention  to 
this  subject  in  a  paper  'On  the  Relation 
of  Disease  of  both  Ovaries  to  the  Ova- 
riotomy Question.'  He  gives  the  result 
of  an  examination  of  the  reports  of  post- 
mortem examinations  for  the  previous 
14  years  by  Virchow  and  Fiirster. 
These  records  were  examined  with 
the  sole  object  of  ascertaining  in  how 
many    cases    one    or   l;)Oth   ovaries   were 


diseased.  In  99  cases  of  ovarian  disease 
it  was  found  that  in  48  one,  and  in  51 
both  ovaries  were  diseased — so  that  in 
more  than  half  the  disease  was  on  both 
sides.  The  tendency  to  disease  of  both 
ovaries  appears  to  be  greater  before  the 
age  of  50  than  in  older  women.  Of  52 
women  under  50,  both  ovaries  were 
diseased  in  31 ;  1  ovary  only  iia  21 
(59  per  cent,  to  40).  Of  44  Avomen 
above  50,  both  ovaries  were  diseased  in 
17  only,  while  1  ovary  was  diseased  in 
27.  Thus,  imder  50,  we  had  both  ovaries 
diseased  in  59  per  cent. ;  above  50,  only 
in  38  per  cent. 

But  it  must  be  remembered  that  any 
conclusion  drawn  from  post-mortem  exa- 
minations would  in  all  p'-obability  differ 
very  widely  from  results  observed  in  ova- 
riotomy. The  first  series  of  facts  shows 
what  may  be  expected  when  ovarian 
disease  has  proceeded  to  its  natural  termi- 
nation, or  lias  only  been  modified  by  pal- 
liative treatment.  The  otlier  series  shows 
what  may  be  expected  when  the  patient  is 
subjected  to  radical  treatment  before  the 
disease  has  advanced  to  its  last  stages.  All 
observation  tends  to  the  conclusion  that 
disease  begins  in  one  ovary  and  advances 
to  a  considerable  extent  in  that  ovary  be- 
fore the  other  is  affected,  and  that  in  about 
half  of  the  cases  it  proceeds  even  to  its 
fatal  termination  without  any  disease 
occurring  in  the  opposite  ovary. 


THE   REMOVAL   OF  BOTH   OVARIES   AT  ONE   OPERATION       101 


If,  then,  in  only  about  half  of  the 
cases  where  ovarian  disease  has  reached 
its  latest  stage,  disease  of  both  ovaries  is 
found,  we  might  expect  that  in  earlier 
stages  of  the  disease  both  ovaries  would 
be  much  less  frequently  affected ;  and  so 
far  as  my  observation  has  gone,  this  is  the 
fact.  In  the  1,139  cases  in  which  I  have 
performed  ovariotomy  I  only  removed 
both  ovaries  in  102  cases.  In  a  few  other 
cases  the  ovary  not  removed  presented 
some  indications  of  disease  in  a  very  early 
stage,  but  not  sufficient  to  warrant  its 
removal. 

It  is  not  improbable  that  in  some  of 
the  earlier  cases  slight  disease  of  the 
opposite  ovary  may  have  been  overlooked ; 
but,  making  every  reasonable  allowance 
for  such  error,  it  is  not  probable  that  both 
ovaries  will  be  found  diseased  in  more 
than  about  10  per  cent,  of  the  patients. 

As  to  the  frequency  with  which,  after 
successful  ovariotomy,  the  ovary  not  re- 
moved, but  examined  and  found  healthy, 
becomes  diseased,  4  came  under  tny  notice 
up  to  the  year  1872,  and  since  then  there 
have  been  10  others. 

In  my  2nd  case,  operated  on  in 
1858,  the  patient  remained  well  for  7 
years.  Then  disease  of  the  opposite 
ovary  appeared,  so  evidently  of  a  malig- 
nant character  that  no  operation  was 
thought  of,  and  soft  cancer  was  found 
after  death. 

In  the  ord  case,  also  operated  on  in 
1858,  the  patient  died  of  peritoneal  cancer 
10  months  after  operation,  and  disease  had 
commenced  in  the  remaining  ovary,  which 
was  enlarged  to  the  size  of  an  apple. 

In  my  43rd  case,  operated  on  in 
18G2,  disease  of  the  opposite  ovary  came 
on  2  years  afterwards,  and  was  treated 
successfully  by  vaginal  tapping  and  drain- 
age. The  patient  remained  well  till  1872, 
when  Dr.  Sadler,  of  Barnsley,  had  again 
to  give  relief  by  vaginal  tapping.  She 
died  in  1874. 

Other  cases  where  disease  occurred 
in  the  ovary  left  at  the  first  operation, 
and  led  to  a  second  ovariotomy  on  the 
same  patient,  are  mentioned  in  the  next 
chapter. 

It  has  been  already  explained  how, 
afler  removing  one  ovarian  tumour,  the 
surgeon  should  examine  the  other  ovary. 
In  the  majority  of  cases  it  is  healthy  and 


whether  any  cysts  projecting  from  its 
surface  should  be  punctured  and  their 
contents  squeezed  out,  or  whether  it  is 
more  prudent  to  be  content  with  the  re- 
moval of  one  ovary,  hoping  that  the  other 
will  never  need  surgical  interference,  or 
postponing  that  interference  till  after 
recovery  from  the  first  operation.  In 
determining  which  practice  to  follow,  the 
age  of  the  patient,  her  conjugal  condition, 
and  the  ease  or  difficulty  with  which  the 
second  operation  could  be  performed,  are 
the  leading  points  for  consideration, 

I  have  little  doubt  that  the  removal  of 
the  second  ovary  does  add  somewhat  to 
the  danger  of  the  operation.    U  we  deduct 
from    the    1,000,    82    cases   where    both 
ovaries  were  removed,  this  would  reduce 
the  number  of  single  operations  to  918 
and  the  deaths  to  204,  with  a  mortality 
of  22-2  per  cent.     But  as  of  the  82  cases 
of  double  ovariotomy  28  died,  the  mor- 
tality is  34-14  per  cent.,  or  more  than  12 
per  cent,  above  that  of  the  single  cases. 
Of  139  cases  since  the  1,000  both  ovaries 
were  removed  in  20 ;   of  these  7  died,  a 
very  large  mortality  compared  with  that 
where  only  1   ovary   was  removed  ;   but 
I  should  add  that  in  2  of  the  7  fatal  cases 
uterine  tumours  were  also  removed,  and 
in  1  the  death  was  caused  by  hsemorrhao-e 
from  a  liver   cyst.     This  is  sufficient  to 
show  that  the  surgeon  should  not  remove 
the  second  ovary   without   good    reason. 
I   have    several   times    been    begged    by 
patients  before  the  operation  to  remove 
the  second  ovary,  even  if  it  were  healthy 
and  the  risk  of  the  operation  increased,  in 
order  that  they  might  be  spared  from  the 
possibility  of  being  again  subject  to  similar 
disease  ;  and  medical  men  have  occasion- 
ally supported  this  not  unnatural  wish  of 
the  patient.     I  have  always  replied  that 
I  should  object  to  the  removal  of  a  healthy 
organ   if   that   removal    endangered    the 
success  of  an  operation  which  was  clearly 
necessary ;  that  the  second  ovary  cannot  be 
removed  without   some  additional  risk; 
that,  as  a  rule,   the  removal  of  one  ovary 
Avould  not  be  followed  by  disease  of  the 
other;    that  the  double   operation  would 
necessarily  render  the  woman  sterile,  and 
that  there  might  possibly  be  some  conse- 
quences of  the  removal  of  both  ovaries 
which  would  be  objectionable  if  not  di- 
rectly prejudicial.     For  these  reasons    I 


should  not  be  disturbed.  But  occasionally  |  am  of  opinion  that  a  healthy  ovary  should 
it  is  more  or  less  enlarged  ;  and  it  becomes  not  be  removed  from  any  woman  at  any 
a  question  whether  it  should  be  removed,  |  age,  unless  Battey's  operation  has  to  be 


102 


OVARIAN    AND  ALLIED  TUMOURS 


considered.  This  subject  will  be  treated 
in  a  subsequent  chapter. 

The  amount  of  apparent  disease  in  an 
ovary  Avhich  would  justify  the  removal  of 
the  organ  may  vary  with  the  age  and  con- 
dition of  the  patient.  In  a  woman  past 
the  ao-e  of  child-bearing  a  sniidl  amount 
of  apparent  disease  would  justify  removal 
of  the  ovary,  whereas  a  surgeon  should 
hesitate  before  he  condemns  a  young 
woman  to  permanent  sterility.  It  has 
been  suggested  that  in  every  woman  past 
the  age  of  child-bearing,  if  one  ovary  has 
to  be  removed  both  should  always  be  taken 
away,  to  avoid  the  possibility  of  recur- 
rence of  disease  calling  for  a  second  ova- 
riotomy. But  one  would  hardly  be  justi- 
fied in  adding  anything  to  the  risk  of  a 
first  operation  on  so  small  a  probability  as 
there  is  of  recurrence  of  non-malignant 
disease  on  the  other  side. 

Sometimes  during  an  operation,  after 
removal  of  one  ovary,  some  slight  altera- 
tion in  the  other  may  be  observed,  and 
the  question  of  removal  of  the  second 
ovary  may  arise.  In  many  of  my  cases 
this  question  has  arisen.  In  my  112th 
case  of  ovariotomy  the  left  ovary  was  en- 


larged to  nearly  double  the  normal  size. 
Two  follicles,  about  the  size  of  cherries, 
were  distended  by  clot.  These  I  laid 
open,  turning  out  their  contents.  The 
operation  was  peculiar  on  account  of  the 
doubt  as  to  the  treatment  of  the  left  ovary. 
I  resolved  not  to  remove  it.  This  opera- 
tion was  performed  in  November  1864. 
The  patient  recovered  well,  was  married 
in  August  1865,  and  is  now  the  mother 
of  8  children.  All  the  pregnancies  and 
labours  were  perfectly  natural. 

Of  the  82  cases  in  which  both  ovaries 
were  removed  at  one  operation,  20  were  50 
years  of  age  or  more,  18  were  between 
40  and  50,  and  31  were  under  40 ;  43 
were  married,  36  single,  and  3  Avere 
widows.     In  1  case  there  were  3  ovaries. 

The  chief  point  of  practical  importance 
in  double  ovariotomy  is  the  mode  of  deal- 
ing with  the  pedicle.  The  results,  before 
adopting  complete  intra-peritoneal  ligature 
and  antiseptic  treatment,  were  strongly  in 
favour  of  the  extra-peritoneal  method  of 
dealing  with  both  pedicles;  but  since  1878 
I  have  always  treated  both  pedicles  by 
the  ligature,  which  has  been  returned  and 
left  within  the  abdominal  cavity. 


CHAPTER   X 

ON    OVAHIOTOMY    PERFORMED    TWICE    ON    THE    SAME    PATIENT 


The  first  patient  upon  whom  I  performed 
ovariotomy,  one  ovary  having  been  pre- 
viously removed,  had  been  operated  on 
by  Baker  Brown  G  months  before  she 
consulted  me  on  account  of  a  recurrence 
of  the  disease.  The  paper  in  which  I 
described  this  case  was  read  beibre  the 
Medical  and  Chirurgical  Society  in  June 
1863. 

My  next  case  is  the  first  in  which 
ovariotomy  was  twice  successfully  per- 
formed upon  the  same  patient  by  the  same 
surgeon. 

1  perfonned  the  first  operation  in  the 
Samaritan  Hospital  on  February  15, 
1865,  The  patient  was  an  immarried 
schoolmistress,  aged  24,  She  was  feeble, 
and  had  a  strumous  appearance.  The 
whole  abdomen  was  occupied  by  an 
irregular  tumour,  in  some  parts  of  which 
fluctuation  was  perceptible.     There  was 


nothing  imusual  in  the  operation.  The 
pedicle  was  3  to  4  inches  in  length, 
extending  from  the  left  side  of  a  long 
thin  utervis;  it  was  secured  in  a  small 
clamp,  and  left  outside  without  trac- 
tion. The  right  ovary  Avas  felt  to  be 
healthy.  About  22  pints  of  fiuid  were 
evacuated,  and  the  more  solid  re- 
mainder of  the  tumour  weighed  about 
7  pounds.  The  patient  rallied  well,  and 
left  the  hospiUd  4  weeks  after  the  opera- 
tion. 

The  patient  remained  Avell  for  more 
than  a  year  after  the  first  operation.  In 
August  1866,  I  found  a  semi-solid  tu- 
mour of  the  right  ovary,  reaching  up  to 
the  false  ribs  on  the  right  side,  in  the 
centre  to  2  inches  above  the  umbilicus, 
and  extending  towards  the  left  side  half 
way  between  the  umbilicus  and  anterior 
superior  spine  of  the  ilium.     The  uterus 


OVARIOTOMY  PERFORMED  TWICE   ON   SAME   PATIENT 


103 


was  freely  movable.     As  there  wus   no 
cyst  large  enough  to  tap  witli  any  liope  of 
affording  even    temporaiy  relief,    I    pei-- 
formed    ovariotomy    August     30,    18GG, 
just    18^   months  after   the   first  opera- 
tion.      Bearing  in    mind   the   sIoav    and 
imperfect   union    in   my   former    second 
operation,  when  I  made  the  incision  very 
near  the  cicatrix  of  the  first    operation, 
I    made    it    in    this    case     1^    inch   to 
the   right   of    the    cicatrix    (which    was 
exactly  in  the  middle  line),  and  carried  it 
from  1   inch   above   the  umbilical  level 
•downwards   for     5     inches.      Its    lowest 
point  was  about  ^  an  inch   higher  than 
the    level   of    the   lowest    point    of    the 
■cicatrix.     A  thin-walled  compound   cyst 
was  closely  adherent  all  over  its  anterior 
surface,  but  the  adhesions  yielded  easily. 
A  broad  thin  pedicle  extended  about  2 
inches  from  the  right  side  of  the  uterus. 
The  uterus  was  in  its  normal  position ; 
but  the  pedicle  of  the  tumour  removed  at 
the  first  operation  passed  from  the  left  side 
of  the  uterus  and  adhered  firmly  to  the 
lower  angle  of  the  cicatrix  in  the  middle 
line  of  the  abdominal  wall.     The  pedicle 
of  the  tumour  about  to  be  removed  was 
enclosed  in  a  broad  clamp,  and  the  tumour 
was  cut  away.     Finding  that  there  would 
be  considerable  traction  on  the  uterus  and 
broad  ligament  if  the    clamp  were  kept 
OTitside,  I  applied  the  actual  cautery  and 
burnt  off  the  portion  of  cyst  left  above  the 
clamp.     The  pedicle  was  allowed  to  sink 
into  the  pelvis.     The  wound  was  closed 
by  silk  sutures.     The  jelly  like  substance 
removed  with  the  fragments  of  the  broken- 
up  tumour,   together  measured  18  pints. 
The    tumour    was    a    multilocular    cyst, 
with  much  tubercular  deposit  in  the  walls 
and  septa. 

The  progress  of  the  patient  after  the 
second  operation  was  quite  as  satisfactory 
as  after  the  first.  After  the  2nd  day 
all  unfavourable  symptoms  ceased,  and 
she  returned  to  Lincolnshire  29  days  after 
the  operation. 

jNote  added  November  13,  18G6. — 
*  I  have  heard  from  her  twice  since  her 
return  home.  The  last  letter  is  dated 
November  10,  1866.  She  says,  "  I  think, 
upon  the  whole,  I  feel  as  well  as  I  did  after 
my  first  operation.  My  voice  is  stronger. 
I  can  sing  the  upper  notes  with  greater 
facility  than  formerly.  I  can  sing  from 
A  up  to  C  natural."  I  was  curious  to  have 
the  range  and  power  of  the  voice  observed 
after  the  removal  of  both  ovaries,  and  it 


could  be  done  with  unusual  accuracy  in 
this  case,  as  the  patient  is  a  teacher  of 
singing.' 

In  1867  this  patient  went  to  reside 
at  Brighton,  and  iulfilled  her  duties  as  a 
schoolmistress  there  for  more  than  a  year. 
I  heard  of  her  more  than  once  as  being  in 
good  health,  but  on  June  30,  18GH,  I 
received  a  letter  from  Mr.  Humphry, 
stating  that  she  had  died  two  days  before, 
and  adding,  '  About  a  week  before  her 
death  I  saw  her  for  the  first  time,  when 
she  had  slight  congestion  at  the  bottom  of 
one  lung.  In  two  or  three  days  this 
subsided,  but  she  seemed  to  get  worse, 
great  prostration,  some  sickness,  small, 
quick  pulse,  restlessness  of  manner,  and 
some  fulness  of  abdomen  leading  me  to 
fear  some  serious  mischief  about  the  seat 
of  the  old  disease.  These  increased,  with 
swelling  of  the  left  leg,  which  was  painless, 
as  was  the  abdomen,  and  she  quickly 
sank.  I  found  about  a  gallon  of  almost 
clear  serum  in  the  abdomen.  No  general 
adhesions.  One  pedicle  adherent  to  lower 
end  of  scar  in  the  abdominal  wall,  and 
adhesion  between  bowel  and  bladder. 
Uterus  very  small  and  elongated,  from 
dragging  to  abdominal  wall  through 
pedicle.  Clot  in  left  iliac  vein.  No  other 
sign  of  disease.  I  could  only  lay  the 
attack  to  cold.' 

The  next  case  where  I  performed 
ovariotomy  successfully  twice  on  the  same 
patient  was  my  30  th  case  of  ovariotomy. 
The  patient  was  single,  50  years  of  age. 
She  had  been  tapped  12  times,  the  quan- 
tity increasing  and  the  fluid  becoming 
thicker  every  time.  The  operation  was 
performed  on  December  17,  1861.  The 
pedicle  was  short,  but  was  easily  secured 
by  a  clamp  about  1  inch  from  the  right 
side  of  the  uterus.  On  examining  the 
left  ovary,  it  was  found  atrophied,  but  a 
thin- walled  single  cyst,  as  large  as  an 
orange,  was  observed  close  to  the  uterus, 
within  the  folds  of  the  left  broad  liga- 
ment. This  was  laid  open  by  an  incision 
and  emptied.  The  wound  was  then 
closed,  with  the  stump  of  the  pedicle  at 
the  lower  angle  of  the  wound.  The  entire 
weight  of  the  tumour  Avas  nearly  40 
pounds.  The  progress  after  the  operation 
was  uninterrupted,  and  on  December  31 
the  patient  was  convalescent. 

For  more  than  5  years  the  result 
was  satisfactory.  But  in  November  1867, 
the  patient  returned  with  a  cyst  in  the 
abdomen  of  aboutthe  size  and  shape  o£ 


104 


OVARL\N   AND   ALLIED   TUMOUKS 


the  womb  at  the  Gth  or  7th  month 
of  pregnancy.  After  tapping,  and  2 
months  of  restorative  treatment,  the  cyst 
being  larger  than  before  tapping,  I  per- 
formed the  second  ovariotomy  on  Feb- 
ruary 5,  18G8.  I  made  the  incision 
parallel  with  the  cicatrix  over  the  linea 
alba,  but  H  inch  to  the  left  of  it, 
and  extending  about  1  inch  lower.  The 
cyst  on  the  left  side  was  exposed  and 
tapped.  The  only  adhesions  were  to  a 
piece  of  omentum,  which  also  adhered  to 
the  abdominal  wall  beneath  the  cicatrix 
and  to  a  coil  of  intestine.  These  ad- 
hesions were  easily  separated.  On  with- 
drawing the  empty  cyst  and  a  group  of 
secondary  cysts,  the  uterus  was  seen  to  be 
held  up  near  the  lower  end  of  the  cicatrix 
by  the  pedicle  of  the  tumour  removed  in 
1861.  The  cyst  on  the  left  side  had  a 
broad  attachment  behind  and  to  the  left  of 
the  uterus.  There  was  not  room  to  apply 
a  cautery  clump  without  injury  to  the 
uterus,  and  I  accordingly  cut  away  the 
base  of  the  cyst,  tying  all  vessels  which 
bled  as  I  went  on,  separating  the  ex- 
tremity of  the  Fallopian  ttibe  from  the 
part  of  the  cyst  to  which  it  adhered,  and 
leaving  a  small  portion  of  cyst  wall  closely 
adhering  to  the  inner  part  of  the  tube 
iind  to  the  uterus. 

The  cyst  weighed  15  ounces  and 
contained  7  pints  of  fluid.  It  was  a 
multilocular  proliferous  cyst  with  very 
vascular  walls.  The  woman  went  on 
well,  although  nervous,  feverish,  and 
subject  to  palpitation,  afterwards  ex- 
plained by  the  discovery  that  she  had  a 
large  secret  supply  of  brandy.  Yet  she 
left  28  days  after  operation,  on  March  5, 
18G8.  She  died  just  8  months  after  the 
second  operation.  There  was  no  post- 
mortem examination ;  the  registered  cause 
of  death  being  '  aberration  of  mind  and 
voluntary  abstinence  from  food.'  I  was 
afterwards  informed  that  she  became 
quite  fleshy,  and  able  to  walk  3  or  4 
miles,  until  she  began  obstinately  to  refuse 
all  food. 

In  one  other  case  I  went  prepared  to 
perform  ovariotomy  upon  a  lady  whose 
right  ovary  I  had  previously  removed ; 
but  I  found  the  uterus  and  left  ovary 
quite  healthy,  and  a  very  thin-walled  cyst 
attached  only  to  the  abdominal  wall,  as 
if  it  had  arisen  at  a  spot  where  some 
firm  adhesions  had  been  separated  at 
the  first  operation.  I  emptied  the 
cyst,  laid    it   freely    open,    and    saw  the 


patient  several  years  afterwards  in  good 
health. 

My  next  case  was  an  unmarried  lady, 
28  years  of  age.  I  performed  the  first 
operation  on  June  11,  1862.  On  opening 
the  peritoneum,  I  found  that  the  tumour 
was  quite  closely  attached  to  the  right 
side  of  the  uterus ;  there  was  nothing  like 
a  pedicle.  I  accordingly  passed  the  chain 
of  an  ecraseur  above  the  Fallopian  tube 
and  below  the  round  ligament,  and 
tightened  it  quite  close  to  the  uterus.  I 
then  cut  away  the  tumour,  and  afterwards 
pared  down  the  stump  nearly  to  the  tight 
chain.  I  then  loosened  the  chain  ;  there 
was  no  bleeding.  So  the  chain  was  re- 
moved, the  pelvis  cleansed,  the  left  ovary 
found  to  be  healthy,  tvi^o  small  pedun- 
culated cysts  of  the  left  broad  ligament 
twisted  off,  and  the  wound  was  closed  by 
two  deep  and  four  superficial  sutures  of 
platinum  wire. 

The  patient  went  out  of  town  on 
June  30,  with  the  wound  quite  healed, 
soon  gained  strength,  Avas  married  in  the 
summer  of  1863,  and  a  fine  strong  child 
was  born  in  August  1861.  The  labour 
was  perfectly  natural. 

A  second  child  was  born  in  February 
1866,  and  the  patient  again  became  preg- 
nant early  in  1867.  Up  to  this  time  the 
health  had  been  very  good,  but  then 
disease  reappeared,  so  that  she  required 
tapping  during  the  pregnancy.  Another 
tapping  followed,  and  a  solid  sub- 
stance of  considerable  size  could  be 
felt  on  the  left  side.  Towards  the 
latter  end  of  May  1868  the  distension 
again  rapidly  advanced.  The  second 
operation,  for  removal  of  the  second 
tumour,  was  undertaken  on  the  21st  of 
June,  1869. 

The  incision  was  made  parallel  with, 
and  ^  an  inch  to  the  left  of,  the 
cicatrix  of  the  first  operation,  extending 
from  the  umbilicus  to  a  point  2  inches 
above  the  pubes.  A  little  ascitic  fluid 
escaped  on  opening  the  peritoneum,  and  a 
coil  of  intestine  was  seen,  as  well  as  a 
large  piece  of  omentum,  which  adhered  to 
the  abdominal  wall  around  the  umbilical 
ring.  On  introducing  the  hand,  and 
pressing  the  intestine  and  omentum  up- 
ward, I  brought  a  tumour  forward  and 
tapped  a  very  thin  transparent  cyst.  Two 
or  three  pints  of  clear  serum  escaped,  and 
I  then  found  a  solid  fibroid  tumour  to  be 
closely  attached  to  the  upper  and  back 
part  of  the  uterus.      A  coil  of  intestine 


OVARIOTOMY  PERFOHMED   TWICE   ON   SAME   PATIENT 


105 


and  a  piece  of  omentum  which  adhered  to 
the  tumour  were  separated  from  it,  and 
the  tumour  Avas  drawn  outward.  Tlic 
chain  of  an  ccraseur  was  then  passed 
behind  the  uterus  around  the  neck  of  the 
tumour,  avoiding  the  right  ovary  and 
right  Fallopian  tube,  which  were  healthy. 
The  chain  was  slowly  tightened,  and  the 
tumour  pared  away  near  the  chain.  One 
omental  vessel  was  tied,  and  the  ligature 
returned  with  the  omentum.  Some 
stitches  were  then  inserted  to  close  the 
upper  part  of  the  wound,  the  chain  of  the 
ecraseur  being  occasionally  tightened. 
As  it  cut  through  there  was  iiree  bleeding, 
and  some  vessels  were  tied  on  the  posterior 
surface  of  the  body  of  the  uterus,  and 
close  to  the  left  Fallopian  tube,  which  had 
been  divided. 

The  uterus  was  again  examined,  and 
perchloride  of  iron  was  applied  to  part  of 
the  surface  where  there  was  some  oozing. 
At  length  the  wound  was  closed,  the 
sutures  being  passed  so  as  to  include  the 
opening  at  the  umbilical  ring,  and  two 
others  beside  the  cicatrix,  where  there 
had  been  hernial  protrusion. 

There  was  some  sickness  during  the 
operation,  and  it  continued  aiterwards. 
She  soon  began  to  show  signs  of  failing 
power,  and  died  66  hours  after  the 
operation. 

At  the  post-mortem  examination  some 
of  the  small  intestines  were  slightly  ad- 
herent from  recent  exudation  of  fibrine. 
The  uterus  and  other  parts  were  sent  to 
Dr.  Wilson  Fox  for  examination,  whose 
report  runs  as  follows  :  '  The  tumour  is, 
I  believe,  a  fibro-sarcoma,  with  a  large 
proportion  of  cells  like  organic  muscular 
iibres,  but  others  are  mere  fibre  cells. 
Besides  these,  there  are  a  great  number 
of  round  and  oval-shaped  nuclei.  The 
tumour  has  under  the  microscope  a  mi- 
nutely lobed  character  ;  i.e.  it  is  traversed 
by  septa  in  all  directions,  and  in  the  septa 
the  muscular  fibres,  and  also  the  fibre 
cells,  are  the  most  abundantly  accumu- 
lated. The  section  is  everywhere  opaque, 
and  glistening  and  firm ;  a  few  stria2  of 
fatty  degeneration  are  seen  in  spots  only. 
Parts  of  the  tumour  are  breaking  up  into 
a  reticular  structure,  in  the  meshes  of 
which  a  clear  serous  fluid  is  contained. 
Various  cysts,  from  the  capacity  of  a  large 
walnut  to  that  of  a  hazelnut,  are  also 
scattered  through  it,  in  addition  to  the 
larger  ones  opened  before.  As  to  whether 
this  tumour  represents  a  sarcoma  of  the 


ovary,  I  am  not  prepared  to  pronounce  a 
positive  opinion  ;  but  in  some  parts  there 
are  little  cavities  with  well-defined  walls, 
which  look  as  if  they  might  be  the 
remains  of  the  Graafian  follicles,  but  the 
walls  are  completely  chanced  by  the  fibro- 
plastic growth,  and  tlieir  lining  does  not 
show  any  remaining  distinct  traces  of  the 
membrana  granulosa.  They  appeared 
empty,  and  two  or  three  times  the  size  of 
the  ordinary  Graafian  follicles.  The 
amount  of  muscular  tissue  present  is  not, 
I  think,  enough  to  invalidate  an  ovarian 
origin.  The  general  character  of  the 
tumour  is  unlike  the  fibroids  of  the  uterus 
which  I  have  seen,  but  I  have  not  made 
these  latter  the  objects  of  a  sufficiently 
comprehensive  study  to  be  able  to  speak 
positively  on  this  point.  If  the  tumour 
is  ovarian,  as  I  am  inclined  to  think, 
there  Avould  appear  to  be  a  double  source 
of  cyst  formation  in  it — one,  the  liquefac- 
tion or  breaking  down  into  cavities,  such 
as  is  seen  in  the  whole  class  of  these 
tumours,  and  the  other,  from  enlarged 
and  altered  Graafian  follicles.' 

During  the  operation,  besides  the 
tumour,  1  found  in  the  abdominal  cavity 
a  free,  sjjheroidal  body,  measiiring  2 
inches  in  its  long  diameter,  1^  inch  in 
breadth,  and  |  of  an  inch  in  thickness. 
Its  Aveight  was  241  grains.  It  was  semi- 
elastic,  of  dark  brownish-yellow  colour, 
and  the  surface  was  smooth  and  shining. 
It  consisted  entirely  of  fat  and  cholesterine 
crystals,  and  had  an  exceedingly  delicate 
investment  of  connective  tissue,  with 
fascicles  of  nucleated  fusiform  cells  and 
elastic  fibres.  This  body  was  evidently 
one  of  the  appendices  epiploica3,  which 
had  separated  irom  its  pedicle,  and  had 
remained  some  time  free  in  the  abdominal 
cavity. 

During  the  attendance  in  1862,  doubt 
arose  Avhether  I  had  been  right  in  de- 
scribing the  right  ovary  as  having  been 
removed  at  the  first  operation  ;  and  the 
second  operation  not  only  justified  the 
doubt,  but  also  suggested  the  question — 
which  even  the  examination  of  the  tumour 
by  Dr.  W.  Fox  did  not  solve — Avhether 
the  tumours  in  either  operation  were  really 
ovarian,  or  fibro-cystic,  or  fibro-sarcoma- 
tous  growths,  originating  in  the  uterua 
and  only  involving  the  ovaries.  A  case 
such  as  this,  which  not  only  shoAvs  the 
difficulties  of  diagnosis  encountered  in 
the  emergencies  of  practice,  but  proves 
how   perplexing,   even  in  the  deliberate 


106 


OVARIAN   AND   ALLIED   TUMOURS 


investigations  of  the  accomplished  patho- 
logist, some  of  the  obscurer  forms  of 
disease  may  become,  should  tend  to 
moderate  any  captiousness  of  criticism  in 
matters  of  practical  surgery,  and  open  up 
the  Avay  to  more  minute  and  recondite 
research  into  the  origin  and  forma  of 
morbid  changes. 

To  these  4  cases  I  have  now  to  add 
9  others,  making  13  in  which  I  have 
removed  an  ovarian  tumour  from  a 
patient  who  had  previously  undergone  the 
operation.  In  11  of  these  patients  I 
performed  both  the  operations  myself  It 
seems  unnecessary  to  make  a  detailed  re- 
port of  the  cases,  but  it  may  be  interest- 
ing to  give  the  dates  of  the  first  and 
second  operations. 


Ko. 

Date  of 
operations 

Eesult 

History  or 
cause  of"  death 

1 

Feb.   1873 
June  1874 
May  1870 
June  1875 
April  1873 
Julv  1876 
May  1869 
July  1876 
Oct.    1872 
Nov.  1876 
Dec.  1865 
Dec.  1876 
May  1S70 
Feb.  1878 
May  1875 
June  1880 
Aug.  1876 
Nov.  1881 

Recovered 
Recovered 
Recovered 
Recovered 
Recovered 
Recovered 
Recovered 
Recovered 
Recovered 

JDiedAp  r 

)  Married  1876 
J  Well  in  1881 
1  Intestine  torn 
J  Well  in  1881 

1  Well  in  1881 
1  Well  in  1881 
1  Well  in  1881 
^  Well  in  1881 
1  Well  in  1881 
j  Well  in  1884 

CHAPTER    XI 

ox    THE    TREATMENT    OF    PATIENTS    AFTER    OVARIOTOMY 


The  treatment  of  patients  after  ovariotomy 
may  be  considered  under  three  distinct 
heads :  first,  the  conditions  imder  which 
the  patient  is  placed,  and  the  duties  of  the 
nurse ;  secondly,  the  medical  treatment ; 
and  thirdly,  the  surgical  treatment. 

A  large,  lofty,  quiet,  airy  room,  neither 
too  hot  nor  too  cold  ;  two  comfortable, 
small,  clean  iron  bedsteads,  with  hair 
mattresses,  and  light,  warm  bedding,  so 
that  the  patient  may  be  lifted  from  one  to 
the  other,  and  have  a  fresh  bed  every 
day  ;  the  personal  linen  so  contrived  that 
it  can  be  changed  frequently  without 
much  disturbance  of  the  patient ;  the 
windows  provided  with  shutters  or  blinds 
disposed  so  as  to  admit  only  an  agreeable 
amount  of  light,  or  to  maintain  a  soothing 
twilight ;  an  open  fire,  wliich,  with  an 
open  window,  secures  a  fitting  tempera- 
ture with  natural  ventilation  ;  a  floor  free 
from  all  woollen  covering  and  painted  or 
varnished  to  facilitate  the  removal  of 
everything  that  could  prove  offensive  or 
hurtful — these  things  together  form  a 
combination  of  favourable  conditions 
which,  imjjortant  in  general  surgery  and 
in  the  treatment  of  every  case  of  severe 
illness,  are  imperatively  necessary  after 
ovariotomy.  It  is  in  attention  to  minute 
details,  and  by  the  observation  of  the  ill- 
effects  which  follow  the  neglect  of  any  of 
them,  that  the  practitioner  is  taught  their 


importance,  and  learns  how  much  of  his 
success  depends  upon  careful  and  intelli- 
gent obedience  in  those  who  are  entrusted 
with  the  care  of  the  patient. 

The  duties  of  the  nurse  are  to  use  the 
catheter  about  every  six  hours,  or  oftener 
if  the  patient  desires  it,  in  order  to  render 
any  movement  or  muscular  eflfort  in 
emptying  the  bladder  unnecessary.  This 
should  be  done  for  3  or  4  days ;  and  it  is 
often  longer  before  a  patient  is  able  to 
dispense  with  the  use  of  the  catheter.  A 
silver  catheter  seems  to  irritate  the  urethra 
and  bladder  less  than  an  elastic  instru- 
ment. Certainly,  troublesome  catarrh  of 
the  bladder  is  more  frequently  noticed 
when  an  elastic  catheter  has  been  used, 
probably  because  it  is  not  so  easily  cleansed, 
and  some  decomposing  mucus  is  intro- 
duced by  it  into  the  bladder.  A  silver 
instrument  is  more  easily  cleansed.  This 
should  be  thoroughly  done  every  time  the 
instrument  is  used,  and  it  should  be  kept 
in  carbolised  Avater.  The  nurse  should 
also  be  capable  of  injecting  into  the  rectum, 
either  small  quantities  of  food,  or  such 
doses  of  some  opiate  as  may  be  found 
necessary  to  relieve  pain.  A  succession 
of  small  opiates,  left  to  the  discretion  of 
an  intelligent  nurse,  with  directions  to 
give  only  enough  to  keep  the  jiatient  free 
from  severe  pain,  answer  better  than 
larger  doses  administered  at  stated  inter- 


TREATMENT   OF  PATIENTS  AFTER  OVARIOTOMY 


107 


vals.  She  should  be  ready  to  supply  the 
patient  either  with  warm  or  cold  drinks, 
or  with  such  light  nourishment  or  stimu- 
lants as  may  be  directed.  Stimulants, 
such  as  brandy  or  champagne,  must  also 
be  left  to  the  nurse,  but  with  explicit 
understanding  that  they  are  only  to  be 
used  when  called  for  by  faintness,  or  chil- 
liness, or  some  sign  of  exhaustion.  Very 
little  food  is  required  during  the  first 
3  days  after  the  operation,  but  there 
should  always  be  at  hand  a  supply  of 
some  light  nourishment,  such  as  well- 
made  barley-water,  toast  and  water,  thin 
gruel,  water  arrowroot,  bread  and  milk, 
chicken  broth  or  beef  tea.  These  the 
patient  may  take  almost  as  freely  as 
she  pleases,  provided  she  is  not  sick. 
Should  sickness  be  troublesome,  a  little 
brandy  in  iced  soda-water,  or  champagne 
iced,  will  probably  relieve  it ;  but  it  is 
often  only  a  sign  of  weakness,  and  is  then 
best  met  by  enemas  of  beef-tea,  either 
with  or  without  egg  and  brandy,  thrown 
into  the  rectum,  in  quantities  of  net  more 
than  2  ounces,  at  short  intervals.  Before 
giving  the  injection,  and  at  any  time 
when  flatulence  is  distressing  a  patient, 
the  nurse  should  introduce  an  elastic 
tube  or  the  injection-pipe  some  2  or  3 
inches  into  the  rectum,  in  order  that  flatus 
may  escape  without  straining  effort,  and 
also  to  allow  of  the  outflow  of  any  pre- 
viously injected  and  unabsorbed  food. 
The  nurse  should  be  able  to  note  varia- 
tions of  the  pulse,  to  take  and  record  tem- 
perature observations  with  the  thermo- 
meter, at  stated  hours,  or  on  the  occurrence 
of  any  febrile  symptoms.  In  cases  of 
drainage,  a  nurse  who  can  be  trusted  to 
attend  to  the  cleanliness  of  the  tube,  to 
draw  off  accumulations  of  fluid,  or  to  in- 
ject antiseptic  solutions,  is  an  exception- 
ally good  one.  The  nurse  should  watch 
the  urine  of  the  patient,  and  should  be 
directed  to  give  the  patient  every  2  or  3 
hours  some  lithia  water,  or  a  mixture  of 
the  citrates  of  potash  and  lithia,  as  soon 
as  it  becomes  scanty  or  concentrated,  de- 
positing urates  on  cooling. 

Beyond  this  administration  of  lithia 
and  potash,  and  opiates  in  sufficient 
quantity  to  relieve  pain,  medical  treatmerd 
may  be  said  to  consist  in  doing  no  harm, 
provided  the  case  go  on  without  any 
serious  complication.  But  if  peritonitis, 
either  of  the  sthenic  or  traumatic  charac- 
ter, or  of  the  septic  variety,  occur,  the 
fever  accompanying   either   form  of   in-  | 


flammation  must  be  watched  ;  and  if  the 
temperature  of  the  body  as  shown  by  the 
thermometer  rises  considerably  above  the 
normal  standard,  means  must  be  taken 
with  the  object  of  lowering  the  tempera- 
ture. Packing  the  arms  and  legs  in  wet 
towels — even  the  cold  bath — has  been 
occasionally  used  in  cases  of  hyperpyrexia, 
but  generally  iceing  the  head  continuously 
is  far  less  disturbing  to  the  patient,  and 
even  more  efficacious.  I  have  tried  the 
cushions  made  of  tubes  for  iced  water, 
introduced  by  Dr.  Roberts,  of  Manchester, 
and  icebags  for  the  neck,  after  Dr.  Rich- 
ardson— but  prefer  Mr.  Thornton's  ice- 
cap for  the  head  to  any  other  arrangement. 
Before  antiseptics,  the  head  Avas  kept  cool 
for  a  day  or  two  in  about  half  the  cases. 
Since  antiseptics,  I  have  scarcely  ever 
found  it  necessary. 

The  bowels  are  kept  quiet  after  the 
operation  ;  and  as  long  as  the  patient  feels 
comfortable,  their  action  needs  not  be 
brought  on,  even  if  they  do  not  act  for 
10  days  or  more.  I  have  known  the 
bowels  to  be  19  days  without  acting,  and 
then  act  naturally  without  any  painful 
effort.  An  enema  of  warm  water  or  a 
dose  of  castor  oil  will  bring  on  their  action 
if  not  spontaneous.  Hard  faecal  masses  in 
the  rectum  may  cause  tenesmus,  keep  up 
a  spurious  diarrhoea,  and  thus  render  the 
patient  uncomfortable.  Their  presence 
will  be  discovered  by  digital  examination. 
They  should  be  broken  up  with  the  finger 
or  a  spoon,  and  the  bowels  afterwards 
cleared  by  injecting  warm  water.  If 
the  first  motion  fatigues  the  patient  and 
renders  her  restless,  it  will  be  advisable 
to  have  it  followed  by  an  opiate  enema. 
Vomiting  is  often  a  troublesome  symptom, 
less  so  when  methylene  has  been  used 
than  after  chloroform.  It  is  sometimes 
relieved  by  giving  small  pieces  of  ice  to 
suck,  or  to  swallow  as  ice  pills;  some- 
times by  draughts  of  hot  water.  But 
this  is  sometimes  dangerous  by  leading  to 
accumulations  of  large  quantities  of  fluid 
in  the  stomach.  If  this  accumulation  and 
consequent  faintness  are  observed,  it  may 
be  necessary  to  empty  the  stomach  by  the 
stomach-pump.  Of  all  medicines,  I  have 
found  15-grain  doses  of  bromide  of  potas- 
sium in  2  ounces  of  water  the  most  use- 
ful. Next  to  that,  3  to  5  drops  of  prussic 
acid. 

Flatulence,  often  a  very  troublesome 
symptom,  may  be  relieved  by  passing  the 
elastic  tube  of   an    enema  apparatus  up 


108 


OVAKIAX   AND   ALLIED   TUMOURS 


the  rectum.  An  enema  of  5  grains  of 
quinine  in  1  ounce  of  water  or  beef-tea, 
•with  or  -without  a  few  drops  of  laudanum, 
or  ^  an  ounce  of  port-wine,  repeated 
every  4  hours,  has  often  relieved  flatu- 
lence by  restoring  the  tone  of  the  muscu- 
lar coat  of  the  intestines,  and  occasionally 
Faradisation  has  proved  useful  in  the 
same  way.  A  few  drops  of  chloric  ether 
and  salvolatile  sometimes  give  relief,  and 
tincture  of  nux  vomica  has  appeared  to 
be  of  use  in  some  cases. 

Surrjlcal  treatment. — The  various  con- 
ditions following  ovariotomy  which  may 
call  for  surgical  treatment  may  be  ar- 
ranged in  order,  commencing  Avith  the 
wound  in  the  abdominal  wall  and  the 
separation  of  the  pedicle ;  next  collec- 
tions of  serum,  blood,  or  pus  in  some 
part  of  the  peritoneal  cavity  ;  and  thirdly 
adhesions  between  the  intestine  and  the 
pedicle,  or  the  abdominal  Avail,  leading 
to  intestinal  obstri;ction. 

Unless  the  abdominal  wall  is  oedema- 
tous,  or  the  dressing  is  moistened,  it  is 
better  not  to  disturb  the  bandage  or 
plaster  until  the  seventh  day  after  opera- 
tion. And  then  it  is  not  necessary  to 
raise  the  plaster  from  the  sides  of  the 
abdomen  :  it  should  be  raised  and  divided 
with  scissors  2  or  3  inches  on  one 
side  of  the  wound,  then  raised  and  di- 
vided on  the  other  side.  In  this  way  the 
wound  may  be  uncovered  without  dis- 
turbing the  patient.  After  removing  the 
gauze  or  wool,  the  plaster  left  on  either 
side  is  used  as  splints,  and  drawn  together 
by  new  plaster  above  and  below  the  Avound 
so  as  to  take  off  all  tension  from  the 
Avound  as  the  stitches  are  removed.  As 
a  rule,  union  takes  place  without  any 
suppuration.  Quite  exceptionally  a  little 
pus  Avill  exude  from  one  or  more  of  the 
points  of  suture.  This  is  not  of  much 
consequence.  Indeed,  since  antiseptics  it 
is  very  rare  to  see  even  a  single  drop  of 
pus.  Three  or  four  times,  before  the  anti- 
septic period,  I  have  seen  considerable 
collections  of  pus  in  the  abdominal  Avail, 
almost  always  in  very  fat  patients.  In 
sucli  cases  care  must  be  taken  to  avoid 
any  dressing  Avhich  Avould  interfere  Avith 
the  free  escape  of  the  pus.  A  pad  of 
boracic  cotton  sliould  be  placed  over  the 
Avound,  and  support  given  by  strips  of 
plaster,  Avhich  draw  up  the  side  pieces  or 
splints.  Kceberle  uses  cotton  threads 
Eteeped  in  collodion  with  the  same  object. 

In   every   case   after  removal  of  the 


sutures,  the  abdomen  should  be  supported 
by  adhesive  plaster  for  at  least  a  fortnight, 
or  until  the  Avound  is  firmly  agglutinated. 
Tympanites,  hiccup,  and  vomiting  might 
separate  the  edges  of  a  Avound  Avhich  had 
united  fairly  Avell,  if  these  edges  Avere  not 
Avell  supported.  In  a  few  cases  I  have 
seen  more  or  less  reopening  of  the  wound  ; 
in  2  the  sutures  Avere  removed  too 
early,  and  the  abdominal  Avails  Avere  not 
supported  by  plaster ;  in  other  2  cases 
there  Avas  pyaemia  or  septicajmia,  and  the 
plastic  process  Avas  slow  on  account  of  the 
state  of  the  blood  ;  in  other  2  cases  the 
accident  was  caused  by  violent  cough  on 
the  7th  or  8th  day,  and  in  one  by 
sneezing  a  day  or  two  after  tlie  stitches 
had  been  removed.  These  three  patients 
recovered,  the  septictemic  cases  died.  I 
have  also  seen  other  cases  Avhere  partial 
reopening  of  the  wound  has  appeared  to 
do  good  by  admitting  of  the  escape  of 
serum.  In  all,  the  stitches  Avere  replaced 
as  soon  as  I  Avas  aware  of  the  occurrence. 
In  two  cases  there  Avas  escape  of  intestines 
and  some  difficulty  in  replacing  them,  but 
the  accident  scarcely  retarded  recovery. 

Unless  the  pedicle  is  very  short,  if  a 
clamp  has  been  used  it  lies  across  the 
lower  part  of  the  Avound,  Avithout  any  de- 
pression of  the  abdominal  wall,  and  the 
patient  is  quite  unconscious  of  its  pre- 
sence. Sometimes,  Avith  a  very  short 
pedicle,  the  clamp  and  the  integuments 
have  been  drawn  almost  doAvn  to  the 
sacrum,  even  then,  Avithout  much  com- 
plaint from  the  patient.  There  has  some- 
times been  protrusion  of  the  pedicle  be- 
hind the  clamp,  separating  the  lower 
edges  of  the  Avound.  When  this  occurs, 
the  loAvest  stitch  should  be  removed,  as 
the  protrusion  is  due  to  obstructed  re- 
turn of  blood  through  the  veins  of  the 
pedicle.  Two  or  three  times  the  protru- 
sion has  been  so  great  that  I  have  passed 
a  pin  through  the  pedicle  behind  the 
clamp,  tied  a  ligature  beloAv  the  pin,  and 
cut  away  both  clamp  and  pedicle  ;  but 
this  was  seldom  necessary,  as  the  swelling 
subsided  soon  alter  the  removal  of  the 
compression  caused  by  the  too  tight 
stitch.  The  clamp  and  the  portion  of 
pedicle  compressed  by  it  generally  fell  off 
from  the  7th  to  the  10th  day,  sometimes 
as  early  as  3  or  4  days,  and  sometimes 
not  for  15  or  more.  It  is  important  not 
to  remove  the  clamp  too  soon,  especially 
if  the  pedicle  is  short,  as  the  newly 
formed  adhesions  between  the  pedicle  and 


TREATMENT   OF   TATIENTS   AFTER  OVARIOTOMY 


109 


the  abdominal  wall  might  give  way,  and 
the  pedicle  sink  into  the  peritoneal  cavity, 
possibly  giving  rise  to  septic  peritonitis 
and  death,  and  probably  leaving  an  open- 
ing which,  after  healing  of  the  skin,  would 
admit  of  the  easy  production  of  a  ventral 
hernia.  But  Avhen  the  clamp  is  only  held 
by  a  few  shreds  of  dead  tissue,  it  may  be 
removed.  A  little  ulceration  of  integu- 
ment from  pressure  of  the  clamp  should 
not  lead  to  the  premature  removal  of  the 
clamp,  as  this  is  of  far  less  consequence 
than  the  risk  of  removing  the  clamp  too 
soon. 

The  delay  in  the  union  at  the  lower 
angle  of  the  wound,  where  the  remains  of 
the  pedicle  are  fixed  in  clamp  cases,  may 
protract  the  complete  cicatrisation  to  the 
3rd  or  4th  week,  but  this  is  of  little  con- 
sequence, and  need  not  interfere  with 
the  movement  of  the  patient.  Where  the 
patient  has  been  treated  by  one  or  other 
of  the  intra-peritoneal  methods,  union  by 
the  first  intention  along  the  whole  length 
of  the  incision  is  usually  complete. 

When  bad  symptoms  follow  ovariotomy 
— pain,  vomiting,  fever  with  abdominal 
distension — the  surgeon  should  suspect 
that  some  fluid,  either  serum,  blood,  or 
pus,  is  collecting  in  the  peritoneal  cavity. 
It  may  collect  in  such  quantity  as  to  give 
rise  to  sensible  fluctuation  fi-om  one  side 
of  the  abdomen  to  the  other.  Or,  in 
smaller  quantity,  it  may  gravitate  to  the 
bottom  of  Douglas's  space,  and  form  a 
tense  swelling  behind  the  uterus,  easily 
felt  through  the  vagina,  although  there 
may  be  no  free  fluid  perceptible  in  the 
abdominal  cavity.  If  the  pedicle  has  been 
treated  by  the  uncut  ligature,  the  ends  of 
the  ligature  passing  through  the  wound 
then  serve  as  drainage  conductors,  and  a 
very  free  discharge  of  fluid  may  go  on  for 
several  days.  Koeberle  prepares  for  drain- 
age by  introducing  strong  perforated  glass 
tubes,  and,  by  the  aid  of  a  syringe  fitted 
to  the  tubes,  he  withdraws  fiuid  several 
times  daily.  Peaslee  advocated  and 
adopted  with  success  this  system  of  drain- 
age, with  the  addition  of  repeated  washings 
out  of  the  peritoneum  with  warm  water 
and  disinfecting  solutions.  In  a  few  bad 
cases  I  have  followed  this  practice,  but 
never  with  success. 

In  most  of  the  cases  reported  by 
Peaslee  as  treated  with  peritoneal  injec- 
tions, the  pedicle  was  dealt  with  after  the 
oldest  method  :  that  is,  it  vvas  transfixed, 
each  half  was  tied,  and  the  ends  of  the 


ligatures  were  allowed  to  hang  out  of  the 
wound.  In  one  case,  the  ligatures  were 
brought  out  through  a  vaginal  canula. 
In  all,  the  convalescence  was  very  tedious, 
and  3  had  septicasmia.  The  most  re- 
markable of  the  whole,  as  regards  the 
treatment,  was  that  in  which  loO  injec- 
tions were  made  into  the  peritoneal  cavity 
in  78  days.  The  last  ligature  came  away, 
and  pus  ceased  to  be  secreted,  on  the 
94th  day  after  operation. 

Whenever  fluid  can  be  detected  by 
vaginal  examination  in  the  neighbourhood 
of  the  uterus  it  is  usually  in  such  quantity 
that  it  must  be  removed.  This  is  done 
either  by  a  straight  or  curved  trocar,  over 
which  an  elastic  catheter  is  fixed,  instead 
of  a  canula.  Or,  by  a  trocar  still  more 
curved,  a  piece  of  drainage-tube  may  be 
inserted  and  fastened,  as  shown  in  the 
next  cut.  I  introduced  such  a  tube  in 
the  following  case,  where  it  led  to  free 
discharge,  which  was  followed  by  complete 
recovery. 

I  performed  ovariotomy  on  a  girl, 
18  years  of  age,  in  the  Samaritan  Ho.s- 
pital  on  June  13,  1864.  Long  and  very 
firm  adhesions  anteriorly  and  in  the  right 
iliac  fossa,  and  a  very  extensive  surface 
of  adherent  omentum,  were  separated 
by  the  hand  with  some  difficulty,  and 
a  close  adhesion  to  the  fundus  of  the 
bladder  was  separated  by  very  careful 
dissection.  The  ovary  appeared  normal, 
while  the  tumour  was  attached  to  its 
external  angle  by  a  narrow  pedicle,  about 
1  inch  in  length.  The  ovary  was,  how- 
ever, removed  with  the  tumour.  A  small 
pedicle  was  secured  close  to  the  uterus  by 
a  silk  ligature,  which  was  cut  off  short 
and  returned.  The  stitches  were  removed 
44  hours  after  operation,  the  wound  being 
perfectly  united.  On  the  3rd  day  after 
operation  some  sharp  pain  came  on,  which 
became  easier  after  a  uterine  discharge 
like  menstruation  appeared.  She  con- 
tinued doing  well  till  the  9th  day,  when 
she  was  found  with  dry  tongue,  dilated 
pupils,  flushed  face,  and  drowsiness.  I 
examined  by  the  vagina  and  rectum,  and, 
detecting  fluid  between  them,  made  a 
puncture  by  a  trocar,  and  let  out  5 
ounces  of  dark  bloody  serum  whicli  had 
a  putrid  ammoniacal  odour.  The  pulse 
sank  from  112  to  95  and  92,  but  mucous 
diarrhoea  came  on,  and  the  typhoid  condi- 
tion was  aggi-avated  next  day.  A-  the 
discharge  from  the  trocar  puncture  had 
ceased,    and    examination   detecte  i    fluid 


110 


OVAEIAN   AND  ALLIED   TUMOURS 


still  in  the  recto-vaginal  space,  I  made 
another  opening  into  it,  and  evacuated  10 
ounces  of  fluid  still  more  putrid  than 
that  of  the  day  before,  and  containing 
pus.  I  then  carried  on  the  trocar  through 
the  opening  made  the  day  before,  and 
drew  a  drainage-tube  through  the  canula 
before  withdrawing  it.  The  tube  was 
then  tied  and  left  lixed,  as  shown  in  the 
diagram.     I  took  great  care  that  it  should 


pass  through  the  lowest  point  where  the 
peritoneum  is  reflected  from  the  rectum 
to  the  vagina.  Very  free  discharge  came 
through  the  tube  for  several  days,  and 
the  general  condition  rapidly  improved. 
The  tube  was  removed  on  July  1,  and 
convalescence  was  rapid. 

The  result  of  my  experience  is,  that 
the  danger  of  puncture  has  been  exagge- 
rated ;  that  the  benefit  of  the  evacuation 
of  fluid  is  very  marked ;  and  that  any 
danger  arises  from  too  early  closing  of  the 
opening,  not  from  the  opening  having  been 
made.  Where  it  is  not  easy  to  pass  a 
drainage-tube,  or  where  it  is  desired  to 
use  antiseptic  injections  as  well  as  to  drain, 
it  is  better  to  leave  a  silver  canula  in 
Douglas's  pouch,  and  to  keep  it  there  by 
the  spring  of  double  silver  wire  as  shown 
in  the  drawing  at  page  44.  It  passes  out 
througli  the  vagina,  and  injections  may 
easily  be  thrown  through  it.  But  this  is 
a  troublesome  detail  of  after-treatment 
which  has  become  extremely  rare  since 
the  adoption  of  antiseptics. 

Tiie  most  alarming  symptoms  which 
occur  after  ovariotomy  are  those  which 
depend  upon  oljstructed  intestine.  I 
heard  of  one  case  which  has  never  been 
recorded,  where  a  coil  of  intestine  slipped 
through  one  of  the  loops  of  wire  used  as 


sutures  for  the  wound,  and  was  tightly 
compressed  when  the  wire  was  fastened. 
In  a  published  case,  there  is  very  little 
doubt  tliat  a  fa3cal  fistula  was  caused  by 
perforation  of  intestine  with  the  stitch 
closing  the  wound.  In  one  of  my  early 
cases,  a  coil  of  intestine  was  compressed 
between  the  pedicle  and  the  abdominal 
wall,  and  I  have  seen  others  since  where 
the  same  accident  would  have  happened 
if  I  had  not  been  on  my  guard.  After 
the  intra-peritoneal  methods  of  dealing 
with  the  pedicle  by  ligature  and  by  cautery, 

1  have  seen  fatal  obstruction  of  the  intes- 
tine caused  by  adhesion  of  coils  of  intes- 
tine around  the  divided  end  of  the  pedicle 
at  such  sharp  angles  that  the  canal  was 
quite  closed ;  and  1  have  seen  adhesion  of 
intestine  to  a  clamped  pedicle  lead  in  the 
same  way  to  obstruction.  The  following 
case  illustrates  the  course  of  the  symptoms 
when  this  dangerous  complication  pre- 
sents itself: 

A  single  woman,  35  years  old,  was  ad- 
mitted to  hospital  in  March  1867.  The 
whole  abdomen  was  filled  by  a  multilo- 
cular  ovarian  cyst.  The  uterus  was 
healthy,  and  its  mobility  free.  Ovariotomy 
was  performed  on  March  27.     A  pedicle, 

2  to  3  inches  broad  at  its  narrowest 
part,  and  about  one- third  of  an  inch 
thick,  connected  the  base  of  the  tumour 
closely  to  the  right  side  of  a  small  hard 
uterus,  of  irregular  shape  from  a  fibroid 
nodular  outgrowth.  A  cautery  clamp  was 
applied,  and  the  pedicle  divided  by  hot 
irons.  On  opening  the  clamp,  the  com- 
pressed and  seared  pedicle  appeared  at 
fii'st  quite  secure.  But  as  the  pedicle  was 
slowly  separating  from  the  blade  of  the 
clamp  to  which  it  adhered,  three  vessels 
bled  freely.  These  were  tied,  and  then, 
as  there  was  some  oozing  of  blood  all 
along  the  line  of  eschar,  I  transfixed  the 
pedicle  close  to  the  uterus,  tied  the  pedicle 
in  two  halves,  and  allowed  it  to  sink  into 
the  abdomen,  after  cutting  off  the  ends  of 
the  ligature  short.  The  left  ovary  was 
healthy. 

The  state  of  the  patient  after  operation 
was  unsatisfactory  from  the  first,  but  there 
was  not  much  pain.  Some  sickness  on 
the  day  after  operation  increased  on  the 
2nd  day,  and  the  abdomen  became 
tympanitic.  On  the  3rd  and  4th  days 
the  vomiting  continued,  a  great  deal  of 
dark-green  or  cofl^ee-coloured  fluid  being 
thrown  up.  A  free  fluid  motion  was  fol- 
lowed on  the  5th  and  Gth  days  by  some 


TREATMENT   OF   PATIENTS  AFTER  OVARIOTOMY 


111 


improvement,  although  the  vomiting  of 
larce  quantities  of  greenish  fluid  con- 
tinued. On  the  7th  morning  the  patient 
appeared  much  better  ;  but  in  the  evening 
the  pulse  was  IGO,  and  she  appeared 
almost  moribund.  Five  grains  of  quinine 
were  given  every  3  hours  by  mouth  and 
rectum.  In  IG  hours  35  grains  had  been 
given,  and  on  the  8th  day  the  pulse  had 
fallen  to  120.  In  the  next  10  days  she 
improved  in  many  respects.  There  was 
no  vomiting,  but  she  suffered  at  times 
with  abdominal  pain  and  much  flatulence. 
On  the  19th  day  she  appeared  remarkably 
well ;  but  at  night,  after  a  free  watery 
motion,  she  suddenly  became  faint  and 
sick,  and  died  on  the  morning  of  the  20th 
day. 

The  wound  was  found  firmly  united. 
There  were  scarcely  any  traces  of  general 
peritonitis.  No  intestine  was  adherent 
near  the  wound,  but  one  coil  slightly  ad- 
hered above  the  umbilicus.  The  uterus 
was  small,  and  had  a  fibroid  nodule  the 
size  of  a  marble  projecting  from  its 
fundus.  The  left  ovary  was  healthy. 
The  pedicle  of  the  tumour  of  the  right 
ovary  was  closely  surrounded — as  shown 
in  the  accompanying  engraving — by  an 


adhering  coil  of  the  ileum  just  before  it 
enters  the  cascum.  About  1  ounce  of  pus 
was  circumscribed  by  this  adhering  intes- 
tine around  the  end  of  the  pedicle,  so  that 
none  of  the    pus  entered  the  peritoneal 


vity.  The  canal  of  the  adhering  coil  of 
p  testine  was  almost  completely  obstructed, 
artly  by  the  sharp  curves  at  Avhich  it 
was  fixed,  and  partly  by  the  contraction 
of  the  adhering  portion,  the  intestine  above 
being  much  distended.  There  was  neither 
blood,  lymph,  nor  serum  in  the  peritoneal 
cavity,  nor  could  any  tubercular  deposit 
be  found. 

In  all  these  cases  the  symptoms  are 
exactly  those  of  strangulated  hernia.  They 
may  be  relieved  by  opium  or  belladonna, 
but  are  almost  certainly  fatal  if  the  ob- 
struction cannot  be  overcome.  More  than 
once  I  have  i-eopened  the  abdomen  and 
separated  adhering  intestine  from  the  ab- 
dominal wall  and  pedicle,  with  temporary 
relief,  but  new  adhesions  folloAved  and  ulti- 
mately death.  I  have  seen  several  cases 
where  symptoms  of  obstruction  have  gra- 
dually disappeared,  and  this  has  led  me  to 
wait  too  long  in  other  cases  before  re- 
opening the  wound  and  searching  for  the 
seat  of  obstruction.  In  one  case  I  might 
easily  have  saved  life  by  separating  a  mere 
film  of  adhesion  close  to  the  wound,  which 
held  a  piece  of  small  intestine  as  sharply 
as  a  ligature.  The  preparation  is  in  the 
Museum  of  the  College  of  Surgeons. 

Two  woodcuts  on  the  next  page  serve 
to  make  clear  a  point  in  anatomy  which, 
from  being  overlooked  or  forgotten,  has 
often  led  to  difficulties  in  diagnosis  and 
sometimes  to  dangerous  proposals  or  mis- 
chievous practice.  It  will  be  seen  by  the 
representation  of  the  perpendicular  section 
of  the  abdomen,  pelvis,  and  their  contents, 
how  under  certain  circumstances  Douglas's 
pouch  may  become  distended  by  fluid 
or  by  a  mass  of  intestines  gravitating  into 
it.  To  be  able  to  make  sure  of  the  nature 
of  the  tu.mefaction  thus  caused,  and  per- 
ceived during  vaginal  examination,  re- 
quires tact  and  experience,  and  I  have  not 
been  surprised  sometimes  to  hear  most 
erroneous  speculations  about  it  and  to  find 
myself  consulted  as  to  operative  measures 
for  its  relief,  under  what  was  supposed  to 
be  the  most  urgent  necessity.  But  a  study 
of  the  relations  of  the  parts  will  show  how 
the  presence  of  small  intestines  filled 
with  fgecal  matter  and  falling  low  down 
into  Douglas's  pouch  between  the  uterus 
and  rectum  may  simulate  abscess  or 
haematocele.  The  drawing  also  explains 
what  a  scope,  when  the  expansion  of  the 
pouch  has  once  begun,  the  space  offers 
for  the  enlargement  of  a  cystic  tumour 
in  that  direction,  and  how  hy  remamiug 


112 


OVARIAN  AND  ALLIED   TUMOURS 


for  some  time  undisturbed  it  may  so  model 
itself  to  the  form  of  the  pelvis  and  to  the 
outline  of  the  organs  in  it,  as  to  be  raised 


with  difficulty  and  so  give  cause  to  fear 
the  presence  of  serious  attachments.  All 
this    explains   one    cause     of    obstructed 


intestine  which  has  hitherto  escaped 
notice.  Adhesion  of  coils  of  intestine  to 
the  pedicle,  to  the  abdominal  wall,  or  to 
neighbouring  coils  of  intestine,   at    such 


sharp  curves  or  angles  as  to  close  the 
canal  have  been  referred  to ;  but  the  fact 
that  this  adhesion  may  take  place  low 
down  in  the  pelvis  at  the  bottom  of  the 


recto-uterine  pouch  has  not  been  men- 
tioned. Yet,  it  is  nft  very  rare,  and, 
though  recognisable  when  understood,  it 


may  be  mistaken  for  abscess  or  hajmatocele. 
The  first  of  the  above  drawings  thows 
how    in  most  adults  some  jiortion  of  the 


TREATMENT   OF  PATIENTS   AFTER   OVARIOTOMY 


113 


small  intestines  sinks  down  in  the  normal 
condition  of  parts  between  the  uterus 
and  the  rectum.  After  ovariotomy,  especi- 
ally when  the  lower  part  of  the  ovarian 
tumour  has  pushed  the  uterus  upwards 
iind  forwards,  a  considerable  space  is  left 
between  the  rectum  and  uterus,  and  into 
this  the  small  intestines  fall  down.  I  have 
often  found  them  there  when  sponging  out 
the  pelvis.  Now,  supposing  them  to  be 
more  or  less  firmly  fixed  there  by  effused 
lymph,  it  is  very  probable  that  some 
obstruction  may  follow,  and  that  a  con- 
siderable swelling  may  be  discovered  be- 
hind the  uterus  on  examining  by  the 
vagina.  Rectal  examination  at  once  shows 
that  it  is  between  the  rectum  and  the 
uterus,  and  probably  that  it  is  more  to- 
Avards  the  right  than  the  left  side.  A 
glance  at  the  second  of  these  woodciits 
shows  why  this  is  so.  The  rectum,  con- 
taining fteces,  fluid,  or  gas,  occupies  the 
left  side  before  it  reaches  the  middle  line, 
and  there  is  more  vacant  space  towards  the 
right  of  Douglas's  pouch  to  admit  the 
small  intestines.  There  they  may  adhere 
ynd  form  a  considerable  swelling. 

Sometimes,  long  after  recovery,  more 
or  less  complete  obstruction  of  intestine  is 
followed  by  the  formation  of  a  fiecal 
fistula.  Such,  cases  are  recorded  by  Lyon 
of  Glasgow,  Keith,  and  Bryant.  Once  the 
same  thing  happened  in  a  patient  of  my 
own.  In  Lyon's  case  the  operation  was 
performed  in  February  1866, '  easily  and 
iavourably.'  Hiccup  and  severe  vomiting 
were  present  for  a  few  days,  and  it  was 
afterwards  found  that  union,  of  the  edges 
of  the  wound  was  imperfect.  A  portion 
of  intestine  was  to  be  seen  adherent  at  the 
bottom  of  the  wound.  Pinlike  perfora- 
tions took  place  in  this,  and  gave  issue  to 
f?3cai  matter  and  offensive  gas.  Various 
means  were  taken  to  obtain  healing,  but 
in  August  1867  the  wound,  or  rather  the 
small  exposed  portion  of  perforated  intes- 
tine, remained  unchanged. 

Dr.  Keith  operated  on  a  patient  in 
whom  at  the  end  of  6  weeks  a  pelvic 
abscess  formed  and  pointed  a  little  above 
Poupart's  ligament.  Some  months  after- 
Avards  there  Avas  a  sudden  escape  of 
coagiilated  blood  iVom  the  rectum,  followed 
by  a  free  discharge  of  pus  from  the  opening 
in  the  groin.  Fascal  matter  soon  made  its 
appearance  and  continued  to  How  till  July, 
Avhen  the  fistula  finally  closed.  This  is 
the  only  case  of  the  kind  which  has  fallen 
to  Dr.  Keith,  and  it  Avas  also  the  only  one 


in  which  at  the  time  he  published  the 
case  he  had  returned  the  pedicle  with  the 
ligatures  into  the  abdomen  after  ovario- 
tomy. 

Mr.  Bryant's  av.qs  a  case  of  successful 
ovariotomy  in  1867.  The  pedicle  Avas 
transfixed  and  tied  Avith  Avhipcord  ;  the 
ends  of  the  ligatures  being  cut  off  they 
Avere  allowed  to  sink  into  the  abdomen 
with  the  pedicle.  These  ligatures  Avere 
discharged  some  months  afterwards 
through  an  artificial  anus  at  the  loAver 
part  of  the  abdominal  Avound,  Avhich  in 
the  end  healed  up  completely. 

The  operation  in  my  case  Avas  per- 
formed on  March  10,  1864  ;  the  patient 
Avas  57  years  of  age.  A  large  multilocular 
cyst  of  the  left  ovary  Avas  removed.  The 
pedicle  Avas  returned  into  the  abdomen 
with  the  ligature.?,  the  ends  of  Avhichwere 
cut  off  short,  close  to  the  knots.  A  por- 
tion of  the  cyst  adhered  so  firmly  in  the 
left  iliac  fossa  that  it  could  not  be  separated, 
and  it  was  left  adherent,  after  transfixing 
and  tying  it,  leaving  the  ends  of  the  liga- 
ture hanging  out  of  the  lower  angle  of  the 
Avound.  The  patient  recovered.  But  5 
weeks  after  the  operation  the  ligatures 
still  kept  the  lower  part  of  the  Avound 
open,  a  little  discharge  daily  escaping 
beside  them.  On  May  31  a  ligature 
came  away,  the  discharge  gradually  les- 
sened, and  the  patient  considered  herself 
to  be  Avell.  In  May  1865  there  Avas  in- 
crease of  discharge  ironi  the  sinus  attended 
with  tineasiness,  but  not  Avith  severe  pain, 
the  odour  of  the  discharge  being  offensive 
— not  putrid,  but  faint  or  albuminOtis. 
Deep  in  the  left  iliac  region  Avas  a  general 
state  of  solidity  of  the  parts,  as  contrasted 
with  the  opposite  side. 

It  should  be  remembered  that,  although 
the  ligature  which  had  been  lelt  hanging 
out  through  the  Avound  in  the  abdominal 
Avail  had  come  away  in  May  1864,  there 
Avas  no  proof  that  the  ligatures  tied  on 
the  pedicle,  and  cut  off  short,  had  come 
away.  It  Avas  thought  they  might  be 
present  and  keeping  up  irritation. 

After  this  the  discharge  became  more 
abundant  and  decidedly  faical,  A'arying  in 
quantity  from  day  to  day.  But  no  solid 
fa?ces  eA'er  passed.  She  gradually  became 
Aveaker,  and  died  December  20,  1865, 
about  20  months  after  ovariotomy. 

I  am  indebted  to  Mr.  T.  P.  Teale  for 
a  report  of  the  post-mortem  examination. 
'  The  fistulous  opening  on  the  surliice  of 
the  abdomen  Avas  larae  enouirh  to  admit 


114 


OVARIAN   AND   ALLIED   TUMOUKS 


the  tip  of  the  little  finger.  Witlain  the 
abdomen  it  Avas  so  dilated  as  to  admit  a 
middle  finger  at  least.  On  opening  the 
abdomen  Ave  found  the  edge  of  the  omen- 
tum adherent  to  the  Avail  at  the  level  of 
the  AA'ound,  a  coil  of  small  intestines 
sealing  the  AA'ound  aboA'e  tlie  fistula,  which 
latter  Avas  at  the  loAver  extremity  of  the 
Avound.  A  small  part  of  the  small  intes- 
tine, the  sigmoid  flexure,  and  the  rectum 
Avere  matted  together  around  the  fistula 
and  the  left  corner  of  the  uterus.  Close 
to  the  left  side  of  the  uterus  Avas  a  mass, 
almost  spongy  and  pedunculated,  Avhich 
projected  towards  the  rectum.  In  the 
centre  of  the  mass  Avas  a  large  suppurating 
cavity,  Avhich  communicated  Avith  the 
fistula  and  with  the  rectum  by  two  large 
openings.  The  cavity  extended  for  some 
distance  between  the  uterus  and  the 
rectum.  It  passed  towards  the  right  side 
behind  the  loAver  part  of  the  uterus ; 
downwards  by  the  side  of  the  rectum, 
and  forAvards  as  far  as  the  femoral  ring. 
No  trace  of  any  ligature  could  be  found. 
The  right  ovary  Avas  healthy.' 

This  case,  and  others,  as  I  have  before 
stated,  influenced  me  in  faA'our  of  the 
extra-peritoneal  treatment  of  the  pedicle. 
The  formation  of  a  sort  of  canal  or  sinus 
by  the  adhesion  together  of  folds  of 
omentum  or  coils  of  intestine,  in  such  a 
manner  as  to  enclose  the  ligature  and 
shut  it  off  from  the  peritoneal  cavity, 
occurs,  I  believe,  Avhen  the  ends  of  the 
ligature  are  not  citt  off.  If  the  patient 
recover,  one  might  expect  more  or  less 
olistruction  of  intestine  to  folloAV  such 
adhesions ;  and  at  page  111  is  a  draAving 
of  a  case  Avhere  such  obstruction  Avas 
proved.  When  the  ends  of  the  ligature 
are  cut  off  and  the  pedicle  returned,  Ave 
knoAv  that  a  similar  adhesion  of  intestine 
.sometimes  takes  place  around  the  end  of 
the  pedicle ;  and  that  in  some  cases  pus 
lias  been  circumscribed  in  this  manner, 
until  at  length  it  has  found  an  outlet, 
cither  through  the  alxlorninal  wall,  the 
vagina,  or  intestine.  The  observation  of 
cases  of  this  kind  led  me  to  believe  tliat 
the  clamp,  or  some  other  extra-peritoneal 
method,  Avasnot  only  successful  as  regards 
the  immediate  result  of  the  operation,  but 
still  more  so  if  avc  looked  to  tlie  subse- 
quent health  of  the  patient.  Patients  Avho 
recovered  after  the  extra-peritoneal  treat- 
ment of  the  pedicle,  as  a  rule  soon  regained 
health.  So  do  those  Avho  recover  after 
the  intra-peritoncal  treatment.    But  some 


of  them,  sooner  or  later,  suffer  from 
chronic  suppuration,  hosmatocele,  or  fcecal 
fistula ;  or,  perhaps  Avithout  any  definite 
local  ailment,  are  many  months  before 
they  become  strong  and  Avell.  This, 
however,  must  be  considerably  modified 
by  what  has  been  observed  since  the  use 
of  antiseptics  ;  for  in  the  6  years  since  I 
ha\'e  combined  the  antiseptic  and  intra- 
peritoneal methods,  I  can  record  rapid 
and  complete  recovery  as  the  rule,  and 
have  not  noted  one  case  either  of  chronic 
suppuration  or  faecal  fistula,  and  only  one 
of  ha^matocele,  and  that  doubtful. 

TETANUS 

If  my  OAvn  experience  of  4  cases 
in  1,139  cases  of  completed  OA'ariotomy 
may  be  taken  as  any  guide  in  estimating 
the  frequency  of  tetanus  after  ovariotomy, 
Ave  might  say  that  it  occurred  once  in 
from  250  to  300  cases.  And  this  estimate 
is  supported  by  the  fact  that  the  300  cases 
collected  by  Dr.  Lyman  Avith  a  vieAV  to 
ascertain  the  causes  of  death  furnished 
only  1  case  of  tetanus.  Olshausen  gives 
a  table  of  20  cases  of  tetanus  after  ovario- 
tomy, and  some  particulars  of  4  others, 
only  1  of  Avhich  (and  that  in  my  own 
practice)  recovered.  It  is  remarkable 
that  Stilling  lost  7  patients  from  this  com- 
plication out  of  a  total  of  29. 

It  is  curious  that,  of  the  4  cases  of 
tetanus  Avhich  have  occurred  in  my  prac- 
tice, 3  showed  themselves  very  early — 
namely,  the  9th,  the  12th,  and  the  o5th 
cases — and  I  did  not  see  another  till  the 
898th ;  a  run  of  more  than  850  ovario- 
tomies Avithout  a  sign  of  tetanus.  I  have 
not  seen  1  in  the  last  241  cases.  The  first 
2  cases  Avere  in  October  1859.  The  3rd 
did  not  appear  till  May  1862,  at  Avhich 
time  several  other  deaths  from  tetanus 
Avcre  registered  in  London,  2  having  fol- 
loAved  the  simple  operation  of  tapping  for 
hydrocele.  From  May  1862  till  June 
]<S78,  or  16  years,  I  saw  not  a  single  case 
of  tetanus,  nor  have  I  since.  Among  all 
my  operations  for  the  remoA^al  of  uterine 
tumours,  ovariotomy  twice  on  the  same 
patient,  incomplete  operations  and  ex- 
ploratory incisions,  there  Avas  not  one 
case  of  tetanus.  Four  cases  of  tetanus 
folloAving  ovariotomy  are  all  I  have  to 
record,  and  this  is  in  the  proportion  of 
less  than  1  in  300  for  all  gastrotomy 
operations.  I  must  certainly  have  tapped 
ovarian   cysts    1,000  times.     I  have    re- 


TREATMENT   OF  PATIENTS   AFTER  OVARIOTOMY 


115 


moved  a  great  many  tumours  of  the  breast 
and  from  other  parts  of  the  body  every 
year;  and  I  have  performed  a  large  num- 
ber of  plastic  operations,  such  as  closing 
vesico-vaginal  fistulaj  and  restoring  rup- 
tured perineum,  tetanus  occurring  only 
once.  Then  it  followed  tlie  operation  for 
ruptured  perineum.  In  this  case,  and  in 
3  out  of  the  4  where  it  happened  after 
ovariotomy,  the  patients  themselves  attri- 
buted the  access  of  the  symptoms  to  a 
chill.  In  the  perineal  case  it  was  very 
remarkable,  as  the  premonitory  stiffness 
and  spasms  appeared  soon  after  the  re- 
moval of  the  patient's  bed  to  a  spot  im- 
mediately beneath  an  open  ventilating 
shaft.  In  1  of  the  ovariotomy  cases  no 
note  has  been  made  as  to  chill ;  but  in 
the  3  others  it  was  distinctly  observed 
that  the  tetanic  symptoms  came  on  after 
an  exposure  to  a  draught  of  cold  air  when 
the  patients  were  incautiously  uncovered. 
As  preventive  treatment,  the  necessity 
of  protecting  women  after  operation  from 
currents  of  cold  air,  or  chill  in  any  way, 
is  clearly  shown.  In  regard  to  curative 
treatment,  it  is  interesting  to  state  that  the 
only  case  of  the  29  collected  by  Olshausen 
which  recovered  was  that  which  I  treated 
with  woorara.  Any  one  wishing  to  follow 
out  this  subject  may  refer  to  a  paper  of 
mine  read  at  the  Medico-Chirurgical 
Society  in  November  1859,  and  published 
in  the  Proceedings.  In  the  other  cases 
chloroform  was  given  freely,  woorara  Avas 
again  tried,  but  without  any  apparent 
good  result,  and  opium  was  used.  All 
treatment,  however,  was  as  ineffectual  as 
it  is  generally  found  to  be,  except  in  the 


very  chronic  cases.  In  1  case  I  excised 
the  remnant  of  the  exposed  pedicle  and  a 
portion  of  omentum  which  had  been  tied 
and  brought  out  thx'ough  the  wound ; 
hoping  that,  as  injured  nerves  in  the 
pedicle  might  be  the  origin  of  some  in- 
jurious reflex  action,  when  the  cause  of 
the  mischief  was  taken  away  there  would 
be  some  mitigation  of  the  symptoms. 
Olshausen  attributes  the  high  mortality 
which  he  has  tabulated  partly  to  the  irri- 
tation of  hare-lip  pins,  but  the  greater  pro- 
portion of  it  to  insufficient  tightness  of  the 
clamp,  indicated  by  secondary  heemor- 
rhage,  so  that  the  nerves  of  the  pedicle 
were  not  so  thoroughly  crushed  as  to 
render  them  powerless  in  exciting  marked 
reflex  action.  Messrs.  Harris  and  Doran 
recently  examined  the  spinal  cord  after 
the  death  of  a  woman  in  the  Samaritan 
Hospital,  and  in  their  report  to  the  Patho- 
logical Society  state  that  they  only  found 
appearances  which  are  seen  after  other 
diseases,  such  as  exudations,  dilated  ves- 
sels, want  of  symmetry,  and  exuberant 
proliferation  in  the  central  canal ;  and 
they  conclude  that  the  clinical  symptoms 
do  not  encourage  us  in  the  expectation  of 
finding  any  specific  change  in  the  cord, 
though  it  is  unquestionably  the  structure 
partly,  if  not  chiefly,  at  fault.  Here  there 
Avas  no  apparent  local  morbid  action,  and, 
so  far  as  my  oAvn  cases  are  concerned,  I 
have  no  reason  to  believe  that  any  patho- 
logical condition  connected  AAath  the 
operation  had  anything  more  to  do  with 
the  disease  than  as  giving  the  same  pre- 
disposition Avhich  Avould  come  from  a 
common  Avound. 


CHAPTER    XII 


OVARIOTOJIY    DURING    PREGNANCY 


Ovarian  tumours  may  not  only  be  mis- 
taken for  pregnancy  Avhen  they  exist 
independently,  but  they  are  often  compli- 
cated by  its  occurrence  even  in  advanced 
stages  of  their  growth.  And  though  the 
diagnosis  of  this  condition  is  generally  to 
be  made  out  by  the  tisual  order  of  exami- 
nation, yet  the  complication  may  be 
revealed  only  at  the  time  of  the  operation. 
Out  of  these  circumstances  several  very 
important  practical  questions  arise. 


It  may  be  asked,  in  the  first  place, 
whether  in  such  a  case  it  Avould  be 
necessary  to  interfere  at  all,  under  the 
assumption  that  pregnancy  and  ovarian 
disease  might  go  on  together,  and  serious 
trouble  arise  only  in  a  small  percentage 
of  cases.  The  early  induction  of  prema- 
ture labour  has  also  been  advocated  on 
the  grounds  that  rupture  of  the  cyst,  or 
its  gangrene  from  rotation  of  the  pedicle, 
might   occur  under  the  pressure  of  the 

I  2 


116 


OVATITAX   AND   ALLIED   TUMOURS 


enlarging  uterus,  Avliile  relief  has  some- 
times i'oUowed  spontaneous  premature 
labour.  Some  practitioners,  again,  have 
declared  themselves  in  favour  of  tapping 
the  ovarian  cyst,  rather  than  inducing 
premature  laboui-,  thus  anticipating  the 
dangers  of  rupture  or  gangrene  of  the 
cyst  without  sacrificing  the  child.  Ami 
then  comes  the  triple  question,  in  refer- 
ence to  ovariotomy,  whether  it  should 
be  performed  at  all  during  the  existence 
of  pregnancy  ;  whether,  if  done,  it  should 
be  supplemented  by  the  Cassarean  section, 
or  Porro's  operation  ;  and  thirdly,  whether 
if,  during  ov^ariotomy,  the  uterus  should 
give  way  or  be  accidentally  opened,  its 
contents  should  be  cleared  out,  or  the 
parts  left  to  themselves,  or  Porro's  opera- 
tion be  peribrmed. 

These  questions  are  of  such  vital 
importance  that  I  will  endeavour  to 
arrive  at  some  general  principles  or  use- 
ful rules  of  practice  by  the  consideration 
of  a  series  of  cases  in  which  the  several 
iifEculties  presented  themselves,  and  will 
lirst  examine  the  assertion  that  no  treat- 
ment at  all  is  called  for ;  that  ovarian  dis- 
ease and  pregnancy  may,  as  a  rule,  be 
allowed  to  progress  together  without 
interference.  I  might  support  this  doc- 
trine by  the  fact  that  I  knew  one  woman 
Avho,  during  the  slow  progress  of  an 
enlarging  ovarian  cyst,  went  through  5 
pregnancies,  bore  5  living  children  with- 
out imusual  difficulty,  although  the  cyst 
had  never  been  tapjied,  nor  had  labour 
ever  been  prematurely  or  artificially 
induced.  And  by  the  fact  that  in 
another  case  where  I  performed  ovario- 
tomy successfully  15  months  after  the 
birth  of  twins,  the  patient  had  begun  to 
enlarge  G  months  before  marriage,  and 
had  only  suffered  from  her  excessive  size 
during  this  pregnancy  ;  and  by  the  fact 
that  a  patient,  upon  whom  I  performed 
ovaiiotomy  with  success  in  the  4th 
month  of  pregnancy,  after  rupture  of  the 
cyst  and  peritonitis,  had  boi-ne  G  living 
children  during  the  progress  of  the  cyst 
before  its  rupture.  But  I  must  regard 
these  cases  as  exceptional,  for  I  can  only 
remember  one  other  case  where  preg- 
nancy complicated  with  ovarian  disease 
lias  gone  on  to  its  natural  termination  in 
the  birth  of  a  living  child  ;  or  where,  in 
consequence  of  non-interference,  great 
suffering  has  not  arisen  during  or  after 
labour,  or  very  grave  danger  from  rup- 
ture or  rotation  of  the  cyst;  or  where  it 


has  not  been  necessary  to  guard  against 
threatening  danger,  and  either  to  tap  the 
cyst,  to  induce  premature  labour,  or  to 
perform  ovariotomy. 

In  the  first  3  cases  which  I  now  pro- 
ceed to  narrate,  death  followed  the  spon- 
taneous rupture  of  an  ovarian  cyst  in  or 
before  the  7th  month  of  pregnancy. 

Case  1. — In  July  1.SG4,  I  saw  a  lady, 
who  with  the  usual  symptoms  of  early 
pregnancy  had  a  hard,  irregular  tumour, 
in  the  right  flank.  The  uterus  Avas 
pushed  a  little  over  to  the  left  side,  and 
the  movements  of  a  child  were  distinctly 
felt ;  while  on  the  right,  not  crossing  the 
median  line,  an  elastic  tumour  extended 
upwards  beneath  the  false  ribs,  I  sug- 
gested that  if  premature  labour  did  not 
come  on,  this  tumour  should  be  punctured. 
In  September  there  was  an  attack  of 
peritonitis,  and  she  was  believed  to  be 
in  labour.  The  membranes  protruding, 
they  Avere  ruptured,  and  some  hours 
afterwards  a  female  child  was  born, 
which  lived  24  hours.  The  symptoms 
of  peritonitis  continued,  and  the  patient 
died  4  days  after  the  delivery. 

After  death  there  was  found  a  very 
large  cyst  of  the  right  ovary,  occupying 
the  whole  of  the  right  side  of  the  abdo- 
men, and  extending  4  inches  to  the 
left  of  the  median  line.  It  was  flaccid, 
as  if  partially  emptied,  and  a  large 
quantity  of  bloody  serous  fluid  lay 
in  the  lower  part  of  the  abdominal 
cavity.  The  pedicle,  Ih  inch  long,  was 
twisted,  and  the  walls  of  the  cyst  were 
infiltrated  with  blood.  Within  the  cyst 
there  was  much  bloody  serum  with  several 
very  firm  clots.  Some  of  the  contents  of 
the  cyst  had  evidently  escaped  through 
an  opening  in  a  very  thin  part  of  the 
cyst  wall  posteriorly,  and  had,  no 
doubt,  caused  the  i^eritonitis  which 
proved  fatal. 

Case  2.— In  May  18G8,  a  lady  in  the 
5th  month  of  pregnancy  was  also  suffer- 
ing from  an  ovarian  tumour,  Avhich  had 
been  discovered  by  her  husband  on  the 
night  of  marriage  in  October  18G6.  From 
the  time  of  marriage,  the  tumour  evi- 
dently but  slowly  increased  in  size,  and 
was  the  seat  of  frequent  darting  pains. 
Eight  months  after  marriage  she  became 
pregnant,  miscarried  C  weeks  after  con- 
ception, and  recovered  without  any  un- 
favourable symptom.  From  this  time  till 
the   end  of  18G7    there  was  no   decided 


OVARIOTOMY  DURTXG   PREGNANCY 


117 


increase  nor  other  change  in  t]ie  tumour. 
Then  a  second  pregnancy  occurred.  She 
began  to  sudor  intense  pain  in  the  tumour, 
and  became  restless  and  desponding.  It 
was  in  the  5th  month  of  this  second 
pregnancy  that  I  saw  her,  and  found  an 
ovarian  cyst  as  large  as  an  adult  head 
above  and  to  the  right  of  the  uterus.  At 
that  time  there  Avas  no  very  great  suffer- 
ing, but  I  advised  that  the  cyst  should  be 
tapped  if  relief  was  called  for.  At  about 
the  6th  month  premature  labour  came 
on  spontaneously,  and  she  was  delivered 
of  a  dead  child.  From  the  period  of  her 
delivery  many  of  her  symptoms  subsided. 
But  after  al^out  a  Aveek  she  began  to 
complain  o£  more  pain  in  the  tumour, 
and  it  increased  rapidly  in  size;  Avhen  one 
morning,  after  turning  somewhat  suddenly 
in  bed,  she  cried  out  that  something  had 
broken  inside,  and  died  almost  instantly. 
No  post-mortem  examination  Avas  made, 
but  the  abdomen  was  found  to  be  per- 
fectly flaccid.  Not  a  trace  of  the  tumour 
could  be  felt. 

Case  3.— On  January  16,  1869,  I  was 
consulted  by  a  lady  24  years  of  age,  Avho 
had  been  married  about  9  months.  She  was 
supposed  to  be  pregnant,  and  an  ovarian 
tumour  had  been  recognised  in  the  left 
side  4  years  before.  The  abdomen 
had  gradually  increased  in  size.  I  could 
distinctly  trace  the  boundaries  of  3 
tumours,  or  separable  portions  of  1 
tumour — one  central,  extending  upwards 
half  Avay  from  the  pubesto  the  umbilicus  ; 
one  on  the  left  side,  extending  into  the 
left  flank  and  reaching  about  1  inch 
above  the  umbilicus ;  and  one  on  the 
right  side,  extending  nearly  to  the  false 
ribs.  The  central  tumour  felt  exactly 
like  a  pregnant  uterus.  The  tumours  to 
the  right  and  left  were  not  fluctuating, 
but  they  felt  softer  than  fibroid  tumours 
of  the  uterus  usually  do.  The  cervix 
uteri  was  shortened  and  softened,  strongly 
supporting  the  belief  in  the  pregnancy. 
But  no  sound  of  foetal  heart  nor  placental 
murmur  could  be  detected.  To  the  left 
of  the  cervix,  projecting  towards  the 
bladder,  a  hard  nodulated  tumour,  as 
large  as  3  or  4  walnuts,  closely 
connected  Avith  the  body  of  the  uterus, 
could  be  felt.  This,  I  felt  sure,  Avas  a 
fibroid  outgroAvth  from  the  uterus,  and  I 
made  a  diagram  illustrating  my  diagnosis 
of  pregnancy  Avith  a  small  hard  fibroid 
outgrowth  from  the  body  of  the  uterus, 
and  two  softer  tumours,  Avhich  might  be 


either  ovarian  tumours  or  soft  uterine 
fibroids ;  and  I  suggested  the  propriety 
of  inducing  premature  labour,  as  I  did 
not  think  that  tapping  could  lead  to  any 
considerable  diminution  in  the  size  of 
either  of  the  tumours. 

A  fortnight  after  this  advice  Avas  given 
the  foetal  heart  was  distinctly  heard.  This 
Avas  on  January  29.  On  February  8,  at  4 
in  the  morning,  she  awoke  after  3  hours' 
sleep,  complained  of  pain,  fell  back,  and 
died.  There  was  no  opportunity  of 
making  a  post-mortem  examination,  but 
there  could  be  no  doubt  about  the  burst- 
ing of  an  OA'arian  cyst. 

Cases  4  and  5. — It  is  unnecessary  to 
detail  the  particulars  of  these  cases,  the 
simple  facts  being  that  two  patients  Avho 
Avere  pregnant  had  also  large  ovarian 
cysts,  Avhich  I  thought  should  be  emptied 
by  tapping,  but  my  advice  was  not  fol- 
lowed. Both  women  suffered  excessively 
from  distension,  had  lingering  labours  and 
still-born  children.  In  both  ovariotomy 
Avas  performed  a  fiew  weeks  after  delivery, 
successfully  in  one,  Avith  a  fatal  result  in 
the  other. 

I  have  also  notes  of  5  cases  of 
patients  Avhom  I  have  tapped  during  preg- 
nancy, 1  of  them  three  times,  1  twice, 
and  3  once.  In  all  these  Avomen  great 
relief  Avas  afforded  by  the  tapping,  no 
ill  effect  of  any  kind  Avas  observed  to 
follow  it,  and  in  all  cases  the  children 
were  born  alive  after  labours  of  mode- 
rate duration.  One  of  these  cases  is 
of  sufficient  interest  to  deserve  a  short 
report. 

Case  6. — In  NoA'ember  1865  I  per- 
formed ovariotomy  Avith  a  successful  result 
upon  a  married  woman,  40  years  of 
age,  4  months  after  the  birth  of  a 
living  child.  I  had  tapped  this  Avoman 
2  months  before  her  delivery,  at  Avhich 
time  the  abdomen  Avas  greatly  distended, 
and  nothing  could  be  detected  except  a 
A'ery  large  ovarian  cj'st,  nor  could  the 
patient  believe  that  she  Avas  pregnant. 
But  the  cervix  uteri  Avas  found  to  be  short 
and  velvety,  and  hallottement  Avas  very 
distinct.  After  the  removal  of  18  pints 
of  fluid,  the  enlarged  uterus  Avas  felt 
nearly  up  to  the  umbilicus,  the  collapsed 
cyst  to  the  left,  and  the  foetal  heart  Avas 
heard  below  and  to  the  left  of  the  umbili- 
cus. Immediate  relief  foUoAved  the  tapping. 
A  healthy  child  Avas  born  on  July  20,  at 
the  fall  term  of  pregnancy.  The  cyst  re- 
filled, and  I  removed  it  in  the  Samaritan 


118 


OVAEIAX   AND   ALLIED   TUMOURS 


Hospital  on  November  29,  1865.  The 
patient  made  an  excellent  recovery,  and 
had  another  child  in  September,  1867. 
I  heard  from  her  in  November,  1881,  as 
being  quite  well. 

As  I  published  a  very  full  report 
of  the  following  case  in  the  '  Medical 
Times  and  Gazette '  of  September  30, 
1865,  I  need  not  do  more  now  than  point 
out  its  bearing  upon  the  question  of  the 
performance  of  ovariotomy  during  preg- 
nancy. In  this  case  I  entirely  overlooked 
the  coexistence  of  pregnancy  with  ovarian 
disease,  and  after  the  removal  of  an 
adherent  multilocular  cyst  of  the  left 
ovary,  weighing  about  28  pounds, 
I  felt  what  I  thought  Avas  a  cyst  of  the 
right  ovary,  tapped  it,  and  then  found 
that  it  was  the  gravid  uterus.  As  this 
stage  of  the  operation  is  of  some  im- 
portance in  the  history  of  the  Cajsarean 
section,  being,  I  believe,  the  first  case  in 
which  the  opening  in  the  uterine  wall  was 
closed  by  sutures,  I  quote  the  following 
passage  from  the  report  published  at 
the  time  : 

'  Some  2  or  3  pints  of  bloody  fluid 
having  escaped  through  the  canula,  the 
tumour  became  much  less  tense ;  and 
on  bringing  it  up  to  the  surface  I  saw  the 
Fallopian  tube  passing  from  its  upper 
part  towards  the  left  side,  and  knew  at 
once  that  I  had  punctured  the  uterus.  On 
withdrawing  the  canula,  a  soft,  spongy, 
bleeding  mass  jirotruded,  and  on  putting 
in  my  finger  to  ])ush  this  back  and  examine 
the  uterine  cavity,  the  anterior  wall  of  the 
uterus — which  was  very  soft  and  friable, 
as  if  it  had  undergone  fatty  degeneration 
— gave  way  along  the  middle  line  from 
the  puncture  (which  was  near  the  fundus) 
for  an  extent  of  from  3  to  4  inches 
down  the  body  towards  the  neck.  With 
very  slight  pressure  a  quantity  of  liquor 
amnii  and  a  fuctus  of  about  5  months 
escaped.  I  then  easily  peeled  olF  the 
placenta  from  the  inner  surface  of  the 
uterus.  The  organ  did  not  contract,  and 
there  was  free  bleeding  from  three  vessels 
close  beneath  the  peritoneum  at  the  lower 
angle  of  the  rupture  in  the  uterus.  These 
vessels  were  secured  by  three  silk  liga- 
tures. Oozing  still  going  on  from  the 
surface  where  the  jilacenta  had  been 
attached,  I  made  a  free  opening  into  the 
vagina  by  passing  my  finger  from  aljove 
through  the  cervix  and  os,  and  then  put  a 
piece  of  ico  into  the  uterus,  and  held  it 
within    by    firmly    gra.sping    the    organ, 


which  then  contracted.  I  then  brought 
the  peritoneal  edges  of  the  tear  in  the 
uterus  together  by  an  uninterrupted  suture 
of  fine  silk,  one  long  end  of  which  I  had 
previously  passed  into  the  uterine  cavity, 
and  out  through  the  os  into  the  vagina. 
By  7  or  8  points  the  edges  were  brought 
accurately  together,  and  the  other  end 
of  the  silk  was  brought  out  through  the 
opening  in  the  abdominal  wall,  with  the 
ends  of  the  3  ligatures  on  the  vessels 
in  the  uterine  wall,  close  to  the  pedicle, 
and  all  were  tied  to  the  clamp.' 

Any  one  interested  in  the  progress  of 
the  patient  after  this  complicated  opera- 
tion may  find  a  very  full  report  in  the 
journal  to  which  I  have  referred.  All  I 
need  say  now  is  that  she  comj^letely 
recovered.  I  have  seen  her  several 
times  since  in  excellent  health,  the  last 
time  in  1880.  She  reported  herself  Avell 
in  1881. 

The  interest  of  this  case  in  relation  to 
the  subject  under  notice  is  in  its  bearing 
on  the  question,  'What  should  be  done 
when  a  pregnant  uterus  is  discovered 
during  some  stage  of  ovariotomy  ?  '  My 
answer  would  be,  '  Let  it  alone.'  But  in 
a  case  of  Dr.  Atlee's  in  1850,  ovariotomy 
performed  in  the  2nd  month  of  preg- 
nancy Avas  '  followed  by  such  great  irrita- 
bility of  stomach,  in  consequence  of  the 
state  of  pregnancy,  that  she  could  not  be 
nourished,  and  she  died,  30  days  after, 
of  starvation.'  And  in  a  case  by  J\Ir. 
Burd,  of  Shrewsbury,  in  1847,  of  ovario- 
tomy performed  between  the  3rd  and 
4th  months  of  pregnancy,  abortion 
took  place  2  days  after  operation,  and 
was  followed  by  alarming  symptoms,  last- 
ing several  days.  Still  the  j^atient  re- 
covered. Marion  Sims  also  performed 
ovariotomy  in  the  3rd  month  of  preg- 
nancy, and  did  not  detect  pregnancy 
until  the  ovarian  tumour  had  been  re- 
moved. The  patient  recovered  well,  went 
the  full  term,  and  Avas  safely  delivered. 

Supposing  the  operator  has  penetrated 
the  uterus,  if  any  conclusion  can  be 
draAvn  from  the  case  in  Avhich  I  made  this 
mistake  and  eu)ptied  the  uterus,  and  from 
two  other  cases  in  Avhich  the  same  mis- 
take Avas  made  by  other  surgeons  Avho 
did  not  empty  the  uterxis,  but  closed  the 
puncture  in  its  Avail  by  Avire  sutures,  both 
I«itients  ha\'ing  died  after  aborting  while 
mine  recovered,  it  Avoidd  appear  to  be 
the  safer  practice  to  empty  the  uterus, 
and   either   to   close  the  opening  in  the 


OVARIOTOMY  DURING  PREGNANCY 


119 


uterine  "vvall  by  suture,  or  to  perform 
supra- vaginal  amputation  of  the  uterus  as 
advised  and  practised  by  Porro,  afterwards 
by  other  Continental  surgeons,  and  more 
recently  here  by  Dr.  Godson,  as  will  be 
seen  by  referring  to  a  subsequent  chapter. 
I  now  proceed  to  relate  4  other 
cases  occurring  in  my  first  series  of 
500,  in  one  of  which  ovariotomy  was 
performed  at  the  4th  month  of  preg- 
nancy, after  rupture  of  the  cyst  and 
peritonitis ;  in  the  2nd,  3rd,  and 
4th  the  operation  was  a  matter  of 
election  to  avoid  other  dangers.  The 
result  was  successful  in  all  of  them,  the 
mothers  being  saved,  o  of  them  giving 
birth  to  living  children  after  natural 
labours  at  the  lull  period  of  pregnancy, 
and  the  4th  having,  recovered  well  after 
a  rapid  labour  11  weeks  after  ovario- 
tomy. 

Case  330. — The  mother  of  8  chil- 
dren, 36  years  of  age,  was  first  seen 
■on  August  13,  1869.  About  a  month 
before  this  an  abdominal  tumour,  which 
had  been  slowly  increasing  after  the  birth 
of  twins  16  years  before,  and  had  not 
prevented  the  birth  of  6  other  children, 
had  suddenly  and  rapidly  increased  in 
size  after  an  attack  of  severe  abdominal 
pain  and  tenderness  with  sickness  and 
lever.  I  ascertained  the  presence  of  an 
ovarian  tumour  with  free  fluid  surround- 
ing it  in  the  peritoneal  cavity,  and  de- 
pressing the  recto- vaginal  pouch,  and  the 
existence  of  pregnancy  about  the  com- 
mencement of  the  4th  month.  The  fluid 
in  the  peritoneal  cavity  was  from  the 
rupture  of  the  wall  of  a  multilocular  cyst, 
and  the  escape  of  the  contents  of  a  large 
cyst.  On  the  following  day  I  performed 
ovariotomy.  The  timiour,  with  its  con- 
tents and  the  fluid  surrounding  it, 
^veighed  altogether  37  pounds. 

This  patient  was  delivered  of  a  living 
child  on  February  IS,  1870,  after  a  natu- 
ral labour,  and  went  on  Avell  afterwards. 
But  she  died  in  1871,  of  malignant  disease 
of  the  uterus. 

Case  399. — In  this  case  a  single  cyst 
was  removed  at  about  the  3rd  month 
of  a  3rd  pregnancy.  A  healthy  child 
was  born  at  the  full  time,  and  3  other 
pregnancies  have  followed. 

Case  419. — A  married  lady,  38  years 
of  age,  mother  of  5  children.  Her  own 
mother  had  died  of  dropsy  and  abdo- 
minal tumour.  A  dermoid  cyst,  without 
pedicle,  but  with  intestinal  and  omental 


adhesions,  and  of  18  years'  growth,  was 
taken  away  about  the  2nd  month  of  the 
6th  pregnancy.  Recovery  complete,  and 
child  born  at  full  time.  Died  10  years 
afterwards  of  pidmonary  disease,  but  had 
also  another  abdominal  tiimour  of  doubt- 
ful nature. 

Case  476.— On  March  13,  1872,  I 
operated  on  a  married  woman  29  years 
of  age  in  the  4th  month  of  pregnancy. 
To  the  right  and  above  the  uterus  was 
a  hard  tumour,  held  up  by  omentum, 
which  adhered  to  it,  and  having  the  right 
Fallopian  tube  only  separated  from  it  by 
the  broad  ligament.  I  cut  away  the 
tumour,  leaving  the  Fallopian  tube  un- 
touched. I  did  not  feel  either  ovary,  the 
uterus  being  so  large  and  tense.  The 
patient  recovered,  was  delivered  of  a 
child  at  the  6th  month  of  pregnancy, 
and  did  Avell,  She  has  since  given  birth 
to  a  girl  at  the  full  time  (1873),  who  is 
still  living.  The  mother  reported  herself 
well  in  1881. 

The  tumour  was  a  nearly  solid  mass 
of  white  fibrous  tissue,  infiltrated  in 
places  with  a  thick  transparent  fluid, 
which  had  here  and  there  collected  in  the 
distended  areoke.  But  towards  the  upper 
part  there  was  a  large  irregular  cavity 
divided  by  imperfect  septa,  lined  with 
smooth  membrane,  and  nearly  filled 
Avith  blood  clot,  partially  organised.  The 
pedicle  was  a  small  double  layer  ot 
peritoneum,  about  1^  inch  long  and 
^  inch  wide,  enclosing  a  few  vessels  and 
some  areolar  tissue.  The  tumour  mea- 
sured in  its  long  diameter  6^  inches  and 
in  its  short  diameter  3^  inches.  It  was 
the  first  fibrous  tumour  of  the  ovary  that 
I  had  seen. 

In  the  second  series  of  500  cases  of 
ovariotomy,  I  performed  the  operation 
during  pregnancy  5  times — making  10 
cases  in  the  1,000.  The  following  are 
brief  notices  of  the  5  cases  which  occurred 
in  the  second  500. 

Case  507. — Was  a  married  woman, 
32  years  of  age,  and  mother  of  7  chil- 
dren. Pregnancy  was  not  suspected,  but 
the  incision  disclosed  a  large  uterus  below 
and  to  the  left  side.  AVith  it  on  the 
right  side  was  a  nuiltilocular  cyst,  weigh- 
ing 26  pounds.  The  left  ovary  was 
found  applied  to  the  side  of  the  uterus, 
which  was  as  large  as  at  the  6th  month  of 
pregnancy.  The  clamp  caused  too  much 
dragging,  and  was  replaced  by  ligatiu'e. 
Labour  pains  came  on  the  next  morning, 


120 


OVAlilAN   AND   ALLIED   TUMOURS 


the  membranes  were  punctured,  and  in 
about  10  minutes  a  living  child  was 
expelled.  The  patient  recovered  rapidly, 
and  after  wai-ds  presented  herself  at  the 
hospital  with  another  healthy  child. 
This  has  since  been  followed  by  another 
birth  and  a  3rd  pregnancy. 

Case  752. — The  lady  was  37  years  of 
age,  at  the  5th  month  of  pregnancy,  suffer- 
ing from  peritonitis  and  obstructed  intes- 
tines, and  almost  moribund.  Some  relief 
Avas  obtained  by  tapping  and  the  removal 
of  9  pints  of  ovarian  fluid  from  the  peri- 
toneal cavity.  The  next  morning  I  took 
aAvay  a  bur.st  ovarian  cyst.  The  child  Avas 
born  9  hours  after.  The  patient  went  on 
well  for  2  days,  but  died  on  the  5th  day 
after  the  operation.  Considering  that 
this  is  the  only  death  after  my  1 1 
operations  daring  pregnancy,  and  the 
desperate  circumstances  under  wliich 
this  one  was  imdertaken,  it  will  certainly 
appear  that  pregnancy  does  not  add  much 
to  the  danger  of  ovariotomy. 

Case  798. — This  lady  was  the  wife  of 
a  medical  man.  She  was  -41  years  of  age 
and  the  mother  of  6  children.  I  re- 
moved an  ovarian  tumour  weighing  7 
pounds.  The  uterus  then  extended  up- 
wards about  half  way  between  the  pubes 
and  umbilicus.  The  pedicle  on  the  right 
side  was  secured  by  a  clamp.  She  re- 
covered perfectly,  was  delivered  after  an 
easy  labour  on  April  23,  LS77,  and  in 
188-1:  was  quite  well. 

Case  817.— The  wife  of  a  soldier 
admitted  into  the  Samaritan  Hospital, 
187G,  Avas  27  years  of  age,  and  had  1 
child  2  years  old.  She  was  in  the  3rd 
or  4th  month  of  pregnancy.  Two  months 
later  the  fa;tal  heart  sounds  were  very 
distinct  in  the  right  iliac  region.  The 
fundus  uteri  was  7  inches  above  the  sym- 
physis pubis,  and  .above  it  Avas  a  large 
ovarian  cyst.  Ovariotomy  Avas  per- 
formed. The  tumour  Aveighed  11^ 
pounds — 9  pints  of  fluid,  2^^  pounds  solid. 
When  she  was  convalescent,  uterine  pains 
came  on  and  a  child  was  born  alive. 
She  has  had  2  boys  since,  1  born  in 
1878,  the  other  in  l.SSO,  and  in  1881  Avas 
quite  Avell. 

Case  879. — The  Avife  of  a  surgeon 
consulted  me  in  October  1877,  4 
months  after  her  marriage.  She  Avas  28 
years  of  age,  and  although  unsuspected 
at  the  time  of  marriage,  there  can  be 
very  little  doubt  that  ovarian  disease 
had  begun  a  year  or  two  before.     She 


Avas  married  on  June  27,  IS77,  and 
pregnancy  may  be  dated  from  the  1st 
Aveek  in  August.  I  operated  on  her 
on  November  9,  1877.  An  ovarian 
tumour  Aveighing  10  pounds Avas  removed, 
a  short  pedicle  on  the  left  side  being 
secured  in  a  clamp.  RecoA^ery  Avas  un- 
interrupted, and  a  child  Avasborn  on  April 
15,  1878.  She  Avas  quite  Avell  in  Aus- 
tralia in  December  1884,  having  had 
four  healthy  children  since  the  ovario- 
tomA^ 

I  have  only  once  operated  during 
pregnancy  since  completing  1,000  cases 
of  ovariotomy. 

Case  1138. — I  performed  ovariotomy 
on  January  22,  1885,  on  a  married  lady 
28  years  of  age.  She  Avas  married  in- 
1881,  had  a  miscarriage  in  July  1882, 
and  until  I  first  saw  her  Avith  Di-. 
Priestley,  in  December  1S84,  suffering 
from  an  OA'arian  cyst  Avhich  Avas  in- 
creasing rather  rapidly,  there  luid  been 
no  suspicion  of  a  subsequent  pregnancy. 
After  removing  a  large  multilocular 
cyst  of  the  left  ovary,  the  uterus  Avas 
seen  to  be  about  the  size  expected. 
A  fa2tus  of  the  3rd  month  came  nvray 
without  pain  or  difficulty  6  days  after- 
Avards.  The  Avound  Avas  quite  healed 
and  the  stitches  removed  on  the  7th  day, 
and  recovery  Avcnt  on  quite  as  Avell  as  iu 
patients  not  pregnant. 

Careful  consideration  of  the  cases  just 
related  Avill  lead,  I  think,  to  the  folloAving 
conclusions : 

1.  Pregnancy  and  OA'aiian  disease  may 
go  on  together.  The  birth  of  a  living 
child  and  the  safety  of  the  mother  have 
been  observed  under  this  complication. 

2.  But  in  a  large  proportion  of  cases — 
probably  in  nearly  all  Avhere  an  ovarian 
tumour  is  large — there  is  danger  of  abor- 
tion ;  or,  if  the  pregnancy  proceed  to  the 
full  term,  of  lingering  labour  and  a  still- 
born child;  and  throughout  the  latter 
months  of  pregnancy  there  is  danger  of 
sudden  death  to  the  mother  from  rupture 
of  the  cyst  or  rotation  of  its  pedicle. 

3.  Spontaneous  premature  lal)0ur  may 
not  save  the  mother  from  these  perils,  and 
the  induction  of  premature  labour  artifi- 
cially almost  implies  sacrifice  of  the  child 
with  considerable  risk  to  the  mother. 

4.  There  is  no  proof  that  tapping  an 
ovarian  cyst  is  more  dangerous  during 
pregnancy  than  at  any  other  time  ;  and  if 
there  bo  a  large  single  cyst,  tapping  Avill 
afford  immediate  relief  to  distension  at  a. 


OVARIOTOMY  DURING   RREG  NANCY 


121 


very  slight  risk  to  the  mother,  and  lead 
to  the  natural  termination  of  pregnancy  in 
the  birth  of  a  living  child,  i£  proper  pre- 
cautions be  taken  to  prevent  the  escape  of 
ovarian  fluid  into  the  peritoneal  cavity, 
and  the  entrance  of  air  carrying  germs  into 
this  cavity,  or  into  the  cavity  of  the  cyst. 
In  cases  of  multilocular  cyst,  tapping  can 
be  of  very  little  use. 

5.  In  cases  of  multilocular  cyst,  or 
solid  tumour,  the  rule  should  be  to  remove 
the  tumour  in  an  early  period  of  pregnancy: 


and  if  an  ovarian  cyst  should  burst  during 
pregnancy  at  any  period,  removal  of  the 
cyst  and  complete  cleansing  of  the  peri- 
toneal cavity  may  save  the  life  of  the 
mother,  and  pregnancy  may  go  on  to  the 
full  term. 

G.  01;  o  cases  on  record  ■where  a  preg- 
nant uterus  has  been  punctured  during 
ovariotomy,  the  only  recovery  was  in  the 
one  case  •where  tlie  uterus  was  emptied 
before  the  completion  of  the  operation,  and 
the  opening  in  its  wall  closed  by  suture. 


Cases  or  Ovariotomy 

DURING  Pregnancy 

No. 

jredical 

Age  of 

Period  of 

Date  of 

Weight 
of 

Result  to 

Result  to  Child 

Subsequent 

Attendant 

Patient 

Pregnancy 

Ovariotomy 

Tumour 

]>J.otUer 

History 

1 

Mr.         Cook, 

24 

4th  to  5th 

Aug.    1865 

28  lbs. 

Recovery 

Foetus  removed 

Well  in  1881 

Clovelly 

month 

at  same  time 

2 

Mr.  Batenian, 

Islington 

3G 

3rd  month 

Aug.    18G9 

S7  lbs. 

Recovery 

Alive  ; 
Natural  lal)our 

Died  of  Cancer 
of  Uterus, 

Feb.  1870 

March  1871 

3 

Dr.  Goddard, 

28 

3rd  month 

Dec.     1870 

15  lbs. 

Recovery          Alive ; 

Children  born. 

Highbury 

Natural  labour 

1873,     1876. 

July  1871' 

1878.  Well 
in  1884 

4 

Dr.          Eoss, 

38 

3rd  month   May     1871  1  34  lbs. 

Recovery 

Alive ; 

Child       born. 

Bloomsbury 

Natural  laliour 
Dec.  1871 

Jan.  7,  1877. 
Pulmonary 
disease    and 
abdominal 
tumour      of 
doubtful  na- 
ture in  1881 

5 

Dr.      Moore, 
Ipswich 

29 

4th  month 

March  1872  1  10  lbs. 

Recovery 

Alive; 

Natural  labour 

jMay  1872 

Child       born, 
Mav      1873. 
Well  in  1881 

6 

Mr.  Coleman, 

32 

7th  month 

Aug.    1872    2G  lbs. 

Recovery 

Seven  months' 

Five     cliildren 

Woolwich 

child,  born  day 
after  operation 

since  —  viz. 
1873-75-76- 
78  and  79. 
Died  soon 
after  last 
birth 

7 

Dr.        Kidd, 
Dublin 

38 

Gth  month 

March  1S76 

40  lbs. 

Died  five 
days  after 

Foetus  expelled 

9  hours  after 

operation 

8 

Dr.    Roberts, 
Cheshunt 

41 

4  th  month 

Oct.      1876 

7  lbs. 

Recovery 

Cliild  born 

April  1877 ; 

Labour  natural 

Well  1884.  No 
more  children 

9 

Surgeon -Ma- 
jor Perry 

27 

7th  month 

Dec.     1876 

12  lbs. 

Recovery 

Child  born 
25  days  after 

Bovs  born, 
1878  &  1880. 

Well  in  1881 

10 

Mr.    Stirling 

28 

4th  month 

Nov.     1877 

10  lbs. 

Recovery 

Child  born  6 
months  after 

Four  children 
since.  Well 
in  Dec.  1884 

11 

Dr.  Priestley 

28 

3rd  month 

Jan.     1885 

15  lbs. 

Recovery 

Abortion     6 
days  after 

Well  March 
18S5 

CHAPTER  XIII 

ON    INCOMPLETE    OVArJOTOMY    AND    EXPLORATOnY    INCISIONS 


When  I  began  to  publish  every  case 
where  I  had  con:ipleted  the  operation  of 
ovariotomy,    and    published,   in  separate 


series,  cases  where  the  operation  was  com- 
menced but  not  completed,  and  caseswhere 
an  exploratory  incision  only  was  made,  I 


122 


OVARIAN  AND  ALLIED  TUMOURS 


had  to  reply  to  objections  advanced  by 
critics  who  considered  that  the  fatal  cases 
of  exploratory  and  incomplete  operations 
ought  to  be  counted  among  the  unsuccess- 
ful cases  of  ovariotomy.  If  I  asked 
whether  the  cases  which  recovered  from 
the  operation  when  only  part  of  the  cyst 
had  been  removed,  or  when  a  cyst  had 
been  simply  emptied,  should  be  counted 
among  the  successful  cases,  the  answer 
was,  '  Certainly  not,  because  ovariotomy 
had  been  only  attempted,  and  the  attempt 
had  failed.'  One  great  reason  why  ovario- 
tomy was  so  long  before  it  was  received 
at  all  cordially  by  the  profession  was, 
that  incomplete  cases,  or  cases  of  simple 
incision,  had  been  classed  among  cases 
of  ovariotomy,  Avhile  unsuccessful  cases 
were  left  unpublished.  In  the  so-called 
statistical  tables,  cases  of  complete  and 
incomplete  ovariotomy  and  of  exploratory 
incisions  were  so  grouped  together  that  it 
was  impossible  to  ascertain,  Avithout  a  good 
deal  of  inquiry,  what  where  the  real 
results  of  even  the  published  cases ;  and 
in  more  than  one  of  the  most  recent  tables 
this  confusion  is  still  more  deplorable. 
Cases  of  abdominal  section  are  confounded 
together,  without  any  separation  of  cases 
of  ovariotomy  from  others  of  very  different 
■character,  thus  grouping  together  sections 
made  with  widely  diverse  objects,  and 
involving  risks,  in  some  very  great,  in 
others  very  slight.  The  best  way  of 
avoiding  this  error  seems  to  be  to  give  a 
truthful  and  exact  account  of  every  case 
of  ovariotomy,  or  of  myomotomy,  neph- 
rectomy, or  of  obstructed  intestine,  or  any 
other  condition  which  leads  to  the  section 
in  the  order  of  its  occurrence.  When 
considering  ovariotomy,  it  should  be 
shown  how  frequently  the  attempt  to 
remove  an  ovarian  tumour  had  been 
made,  how  often  it  had  .succeeded,  what 
were  the  results  of  completed  operations, 
how  often  the  attempt  had  been  only 
partially  successful  or  had  failed,  Avhat 
were  the  results  of  incomplete  operations, 
how  often  diagnosis  had  been  so  doubt- 
ful that  an  exploratory  incision  was 
necessary  before  the  doubt  could  be 
solved,  and  what  risk  the  i)ationt  incurred 
by  submitting  to  an  exploratory  incision. 
This  plan  appeared,  and  still  app-^ars  to 
be,  better  calculated  than  any  other  to 
present  a  true  picture  of  the  occurrences 
of  actual  daily  practice;  and,  I  think,  the 
tables  which  I  published  in  1872,  includ- 
ing every  case  where  I  completed  ovario- 


tomy, and  every  case  where  I  had  not 
completely  succeeded,  or  had  made  an 
exploratory  incision  either  to  satisfy  my 
own  doubts  or  those  of  others,  or  in  com- 
pliance with  the  earnest  solicitation  of  a 
patient,  gave  far  better  means  of  forming 
a  correct  estimate  of  the  real  results 
of  ovariotomy  than  if  the  52  cases 
which  the  supplementary  tables  contained 
had  been  included  among  the  completed 
cases  of  ovariotomy.  The  proportionate 
mortality  would  have  been  slightly  in- 
creased. Instead  of  500  cases,  with  127 
deaths,  and  a  mortality  of  25'4  per  cent., 
we  should  have  had  552  cases,  with  146 
deaths,  and  a  mortality  of  26*44  per  cent, 
—a  difference  of  not  much  more  than  1 
per  cent. — Avhile  discredit  would  have 
been  thrown  upon  the  whole  series  of 
cases  by  the  manifest  fallacy  that  cases 
were  enumerated  as  ovariotomy  where  the 
operation  had  only  been  begun  and  could 
not  be  finished,  and  that  the  patients  who 
recovered  from  the  operation  were  not 
cured  of  the  disease  even  if  they  gained 
some  temporary  benefit.  By  correctly 
classifying  all  the  cases,  as  I  did  in  three 
series,  all  possible  objection  was  removed. 
The  tables  show  that  while  in  some 
14  years  the  operation  of  ovariotomy  had 
been  completed  by  me  500  times,  it  had 
during  the  same  period  been  found  im- 
possible to  complete  it  in  28  cases,  and 
that  in  24  other  cases  exploratory  incisions 
were  necessary  to  perfect  diagnosis. 

On  looking  over  in  1881  the  tables 
published  in  1872,  and  in  adding  cases  of 
exploratory  and  incomplete  operations 
between  these  years,  33  in  number, 
making  85,  to  the  1,000  completed  ovario- 
tomy cases,  I  found  that  in  almost  every 
case  doubts  or  suspicions  entertained 
before  the  incision  was  made  were  con- 
firmed, and  I  scarcely  recollect  a  case 
where  an  exploratory  incision  was 
thought  to  be  necessary  Avhich  proved  to 
be  an  ordinary  case  of  ovarian  disease. 
My  experience  since  1881  confirms  my 
former  statement,  that  occasionally,  after 
commencing  by  an  exploratory  incision, 
I  have  found  it  possible  to  remove  an 
ovarian  tumour,  but  there  has  always 
been  some  peculiarity  in  the  case 
which  led  to  this  unusually  cautious 
mode  of  procedure.  Anyone  who  Avill 
carefully  study  the  chapter  on  diagnosis, 
in  the  earlier  part  of  this  volume,  will 
find  good  reason  for  believing  that  the 
diagnosis  of  ovarian  tumours,  and  of  the 


INCOMrLETE   OVARIOTOMY   AND  EXPLORATORY  INCISIONS 


conditions    fuvourable   or   otherwise   for 
operation,  is  already  as  "well  established 
as   that    of  any    other   form   of  disease 
requiring  surgical  operation.     No  surgeon 
about  to  attempt  to  relieve  a  strangulated 
hernia  can  foresee  exactly  the  conditions 
he  may  meet  with.     The  lithotomist  may 
find  a  larger   or  smaller  stone  than  he 
expects ;  aneurism  is  not  always  cured  by 
the  ligature  of  the  artery  supposed  to  be 
involved;    and  mammary  tumours  sup- 
posed  to   be    malignant   are   found    not 
to  be  so  in  some  cases  after  removal,  or 
those   supposed  to  be  innocent  prove  to 
be  malignant.       Indeed,    throughout   all 
surgery   we   share    with    physicians   the 
difficulty  of  p]-actising  an  ars  conjectiuxdis, 
and  it  is  no  repi'oach  to  a  surgeon,   if, 
acknowledging  doubt,  he  endeavours  to 
clear  up  that  doubt  by  commencing  his 
operation  with    an  exploratory    incision. 
With  our  present  knowledge  it  is  almost 
incomprehensible    that    Frederick    Bird 
should   have    been    compelled  by  Caesar 
Hawkins  to  acknowledge  that,  in  addition 
to  the  few  cases  of  ovariotomy  which  he 
had  completed  and  published,  he  had  also 
made  exploratory  incisions,  or  had  com- 
menced the  operation  and  had  failed  to 
complete   it,    in  about    40    other    cases. 
And  there    can    be    no   doubt  that  if  a 
surgeon  for  every  case  of  completed  ova- 
riotomy must  necessarily  encounter  such 
difficulties  that  he  would  be   compelled 


tube  and  antiseptic  injections,  the  risk 
of  pyajmic  fever  or  septicaemia  must  be 
encountered  ;  but  in  several  cases  a  cure 
has  been  obtained.  In  one  case  which  I 
operated  on  in  18G5  in  the  Samaritan 
Hospital,  where  an  ovarian  cyst  depressed 
the  anterior  wall  of  the  vagina  and 
extended  4  or  5  inches  above  the 
umbilicus,  I  made  an  incision  from  I 
inch  below  the  umbilicus  downwards  for 
5  inches.  There  were  no  adhesions 
anteriorly,  but  after  tapping  the  principal 
cyst,  and  emptying  it  of  several  pints  of 
fluid  containing  much  blood,  its  attach- 
ments to  the  brim  of  the  pelvis  and  to  the 
right  side  of  the  uterus  were  found  to  be 
so  close  that  I  resolved  not  to  attempt 
their  separation,  but  to  replace  the  empty 
cyst.  There  was,  however,  such  free 
hajmorrhage  from  the  opening  into  the 
cyst  made  by  the  trocar,  and  even  from 
the  little  ^^unctures  made  by  the  hooks 
which  seized  the  cyst  wall,  that  it  was 
obviously  imsafe  to  return  it;  and  I 
transfixed  the  edges  o£  the  external  pari- 
etal wound,  and  of  the  cyst  wound,  Avith 
a  hare-lip  pin,  and  secured  them  together 
with  a  twisted  suture.  The  rest  of  the 
abdominal  wound  was  closed  with  4 
deep  silk  sutures  above  the  pin,  and  1 
below  it.  The  patient  rallied  well,  but 
for  a  few  days  had  feverish  symptoms. 
The  stitches  were  removed  in  due  time, 
and   a    very   free    discharge    of    serum 


to    leave    several   cases    incomplete,    or  [  gradually  set  up,  just  at  the  point  where 
repeatedly   meet  with    such   insuperable  I  the  cyst  had  been  pinned  to  the  abdominal 


difficulties  in  diagnosis  that  he  could  only 
satisfactorily  clear  them  up  by  an  incision, 
it  would  be  a  very  grave  objection  to  the 
principle  of  the  operation.  Happily,  with 
advancing  knoAvledge  doubts  are  being 
cleared  up  and  difficulties  lessened,  ex- 
ploratory incisions  are  becoming  less  fre- 
quently necessary,  and  incomplete  are 
bearing  a  diminishing  proportion  to  com- 
plete operations. 

Of  late  years  simple  exploratory''  inci- 
sions, made  under  due  precautions  against 
septicasmia,  have  been  almost  free  from 
risk.  If  a  cyst  be  simply  tapped,  the  risk 
is  hardly,  if  at  all,  greater  than  that  of  an 
ordinary  tapping,  and  the  patient  is  neither 
more  nor  less  relieved.  Where  adhesions 
are  separated  and  portions  of  a  cyst  or 
tumour  are  removed,  the  danger  is  con- 
siderably increased.     When  a  permanent 


wall.  Convalescence  progressed.  There 
was  but  a  very  little  discharge  from  the 
bottom  of  the  cicatrix,  and  a  slight  hard- 
ness and  elastic  swelling  felt  per  vaginam. 
The  abdominal  tumour  disappeared,  and 
I  saw  her  in  1872  in  excellent  health, 
without  any  trace  of  her  tumour. 

In  another  case  the  patient  was  in 
good  health  for  nearly  3  years  after  the 
operation,  and  then  died  almost  immedi- 
ately after  a  subcutaneous  injection  of 
morphia,  in  Germany. 

In  May  1877,  I  attempted  to  remove 
an  ovarian  cyst  from  a  girl,  17  years  of  age, 
ii^  the  Samaritan  Hospital.  I  found  such 
inseparable  attachments  that  I  contented 
myself  with  clearing  the  cyst  cavity  of 
G  pints  of  purulent  fluid  and  flakes  of 
lymph,  closing  the  cyst  and  abdominal  wall 
round  a  glass  tube,  and  covering  the  end 


opening  of  the  cyst  by  incision,  and  imion  i  of  the  tube  with  a  carbolised  sponge, 
of  cyst  wall  to  abdominal  wall  by  suture  i  The  patient  remained  in  the  hospital  till 
is   accomplished,  even   with  a  drainage.  |  August  16,  suffering  from  a  good  deal  of 


124 


OVARIAN  AND   ALLIED   TUMOURS 


fevei',  treated  l3y  the  ice-cap  and  quinine, 
■while  tlie  cyst  was  washed  out  with  car- 
bolised  solutions.  Aftei*  she  left  the 
hospital  sulphurous  acid  was  substituted 
for  the  carbolic  with  an  immediate  change 
for  the  better.  A  continuous  stream  of 
the  diluted  solution  Avas  kept  running 
through  the  cyst  by  a  siphon  arrangement, 
and  at  the  same  time  she  was  vigorously 
nourished.  She  recovered  sufficiently 
well  to  become  a  nurse,  although  there 
was  at  times  some  discharge  from  the 
sinus  in  the  abdominal  wall  which  never 
entirely  closed.  She  was  nursing  in  the 
Samaritan  Hospital  in  the  early  part  of 
1881,  but  died  towards  the  end  of  the 
year,  or  the  beginning  of  1882. 

In  1880,  and  in  18(S1, 1  twice  laid  open 
adherent  cysts,  but  did  not  attempt  to 
remove  them,  trusting  to  the  free  escape 
of  their  fluid  contents  into  the  peritoneal 
cavity  and  absorption.  In  neither  case, 
so  far,  has  there  been  any  sign  of  reforma- 
tion of  fluid. 

The  painful  position  of  a  surgeon  who 
lias  laid  bare  an  ovarian  tumour,  has 
partly  emptied  it,  has  separated  some 
adhesions,  and  then  begins  to  fear  that  he 
cannot  completely  remove  the  tumour,  can 
only  be  estimated  by  those  who  have  un- 
expectedly found  themselves  in  similar 
difficulties.  If  the  difficulty  is  recognised 
early,  and  the  cyst  only  exposed  and 
emptied,  the  patient  is  scarcely  in  a  worse 
condition  than  after  tapping.  Indeed,  the 
incision  leads  to  the  avoidance  of  some  of 
the  dangers  of  tapping  ;  the  surgeon  can 
see  what  vessels  he  wounds,  and  he  can 
close  the  opening  in  the  cyst  if  he  please, 
while  a  short  incision  in  the  abdominal 
wall  can  by  itself  add  little  to  the  risk  to 
the  patient.  But  if  extensive  adhesions 
have  been  separated,  the  surgeon  is  tempted 
at  any  risk  to  complete  the  operation  by 
the  feeling  that  he  can  hardly  leave  his 
patient  in  a  worse  state,  and  that  her  only 
hope  is  in  his  boldly  following  out  his 
intentions.  In  the  very  first  case  I  ever 
operated  on,  the  patient  recovered  from 
the  incision,  died  4  months  afterwards 
from  spontaneous  rupture  of  the  cyst  into 
the  peritoneal  cavity,  when  it  Avas  found 
that  there  would  have  been  no  insuper- 
able difficulty  if  the  operation  had 
been  proceeded  with.  On  the  other 
hand,  post-mortem  examination  has 
shown  that  some  of  the  tumours  could 
not  have  been  removed  during  the 
life  o£  the  patient,    as   they    could   only 


be  separated  after  death  by  careful 
dissection. 

In  any  case  Avhere  difficulty  threatens 
to  be  insuperable,  rather  than  persevere  at 
any  risk,  the  surgeon  acts  more  prudently 
if  he  trusts  to  antiseptic  drainage  after  one 
or  other  of  the  methods  just  described. 

A  simple  mode  of  drainage  is  described 
by  Dr.  Robertson  in  the  first  number  of 
the  'Medical  Chronicle,'  published  at 
Manchester,  October  18S4.  The  object 
in  this  plan  of  draining  is  the  absolute 
exclusion  of  air  both  from  the  cavity 
containing  the  fluid  and  from  the  drain- 
ing apparatus.  Its  peculiarity  consists  in 
the  fixing  of  an  air-trap  to  the  free  end 
of  the  rubber  draining-tube.  This  traj) 
is  merely  a  V-shaped  piece  of  glass 
tubing,  each  arm  measuring  from  2  to  .'> 
inches.  The  discharge  is  conveyed  from 
the  trap  into  any  convenient  receptacle 
by  a  second  piece  of  tubing. 


When  this  apparatus,  filled  with  an  anti- 
septic solution  of  corrosive  sublimate, 
1-1000,  is  properly  fixed  in  a  cyst  or 
abscess,  the  contents  flow  in  obedience  to 
the  laws  that  regulate  the  movements 
of  fluids.  Proper  precautions  are  taken 
in  the  introduction  of  the  tube  into  the 
wound  or  cavity  to  prevent  the  access  of 
air  by  the  opening.  To  secure  its  action 
the  trap  is  fixed  below  the  level  of  the 
abscess  or  cyst,  and  the  draining  force  is 
measured  by  the  perpendicular  distance 
between  the  fluid  level  of  the  cavity  and 
the  fluid  level  of  the  trap.  The  longer 
the  distance  the  greater  the  force.  In 
draining  for  an  amputation,  a  fall  of  I 
inch  serves  the  purpose.  In  cysts  or 
abscesses,  2  or  3  inches  to  a  foot  may  be 
employed  so  long  as  the  discharge  is  free. 
Excess  of  force  is  indicated  by  obstruction 
of  tlie  tube,  due  to  the  tissues  being  sucked 


OOPHORECTOMY — OR  BATTEY'S   OPERATION 


^2o 


into  it,  or  by  the  recurrence  of  pus  after 
the  discharge  has  become  serous.  If  used 
in  a  case  of  incompleted  ovariotomy,  the 
opening  in  the  abdominal  wall  and  tlie 
cyst  cavity  would  of  course  be  accurately 


closed  around  the  tube.  If  used  as  a 
supplement  to  tapping,  it  would  be  neces- 
sary to  use  the  trocar  and  elastic  canula, 
afterwards  fitting  the  tube  over  the  end 
of  the  canula. 


CHAPTER    XIV 

OuPIIOIiECTOMY on    BxVTTKY's    OPERATION' 


There  are  no  means  of  iudofing  what  \ 
Avould  be  the  risk  of  simple  castration  in 
healthy  adult  women.  But  from  what  we 
know  of  it  as  practised  on  the  lower 
;mimals,  the  risk  would  probably  be 
trifling. 

Modern  surgery  has  shown  what  can 
be  accomplished  in  extirpating  ovarian 
cysts,  and  with  what  small  danger.  With- 
out this  demonstration  no  one  Avould  have 
thought  of  treating  functional  diseases  of 
the  ovaries  by  the  same  surgical  operation. 
Battey  did  this  when  he  castrated  a  young 
woman  in  1872,  acting,  as  there  is  reason 
to  believe,  independently  of  any  acquaint- 
ance with  the  suggestion  made  by  Blundell 
in  1823,  that  'extirpation  of  the  ovaries 
would  probably  be  found  an  effectual 
remedy  in  the  worst  cases  of  dysmenorrho3a 
and  in  bleeding  from  monthly  determina- 
tion in  the  inverted  womb  where  the 
extirpation  of  that  organ  was  rejected.' 
Though  the  procedure  had  about  it  an  air 
of  plausibility,  it  was  a  piece  of  surgery 
about  on  a  par  Avith  amputating  for  an 
aneurism.  Battey  had  to  deal  with  organs 
supposed  to  be  at  fault,  and  to  prevent  the 
mischief  they  were  causing,  all  other 
treatment  having  failed.  Two  alternatives 
Avere  at  his  choice ;  he  could  either  cut 
out  the  ovaries,  or  he  could  try  to  bring 
about  their  atrophy.  He  took  the  first, 
and  nothing  in  Avhat  he  has  said  or  written 
shows  that  he  ever  thought  the  second 
possible. 

When  Bell  snipped  out  part  of  a  nerve, 
or  when  the  surgeons  of  today  have 
stretched  a  nerve  to  stop  a  neuralgic  pain, 
a  well-known  principle  guided  them.  So 
it  was  with  Hunter,  when  he  tied  the 
femoral  artery  to  cure  aneurism  of  the 
popliteal.  And  Nature  herself  has  recourse 
to  the  same  device  in  twisting  the  pedicle 
of  an  ovarian  tumour.  But  it  is  not 
always  so  easy  as  it  might  seem  to  carry 


out  scientific  principles  in  surgical  prac- 
tice. No  one  had  tied  the  spermatic 
artery,  and  no  one  had  cut  or  stretched 
the  spermatic  nerve,  and  Battey  cautiously 
Avithheld  his  hand  from  such  experimental 
practice.  Ovariotomists  had  shown  him 
what  was  Avithin  his  power,  and  he  elected 
to  try  that  which  Avas  possiljle  and  easy. 
So  the  science  of  the  19th  century 
has  had  for  a  time  to  give  place  to  the 
rude  chirurgical  art  of  the  17th.  Other 
surgeons  have  accepted  this  position,  and 
have  repeatedly  extirpated  the  normal 
ovaries  of  Avomen. 

Battey 's  object  Avas  to  bring  about 
premature  cessation  of  menstruation  in 
Avomen  who  suffer  from  the  malperform- 
ance  of  their  monthly  functions ;  but 
others,  as  Hegar,  have  given  a  Avider 
range  to  the  idea  of  suspending  the  func- 
tions and  influence  of  the  ovaries.  They 
remove  them  to  stop  the  growth  of  uterine 
fibroma  or  myoma,  thereby  lessen  their 
hoBmorrhagic  tendencies,  and  lead  to  atro- 
phy of  the  growths.  And  the  amount  of 
success  which  I  and  others  have  obtained 
in  cases  of  bleeding  uterine  myoma  by 
removing  the  OA^aries,  is  quite  sufficient  to 
justify  the  proceeding  in  cases  Avhere  the 
removal  of  the  uterine  tumour  Avould  be 
very  difficult  or  dangerous.  But  the  ex- 
tension of  this  practice,  or  the  carrying 
out  of  Battey's  proposal  far  further  than 
he  ever  advocated  or  intended,  is  so  open 
to  abuse,  that  in  mental  and  neurotic 
cases  it  is  only  to  be  thought  of  after  long 
trials  of  other  tentative  measures  and  the 
deliberate  sanction  of  experienced  prac- 
titioners. 

In  the  case  of  fibroid  groAvths  Avith 
much  bleeding,  the  position  is  not  the 
same.  There  life  is  threatened,  the  danger 
constantly  increasing,  and  the  last  resource 
the  very  serious  operation  of  amputation 
of  the  tumour  or  of  the  uterus.     If  it  can 


126 


OVARIAN  AND   ALLIED   TUMOURS 


be  proved  that  the  annulment  of  ovarian 
function,  even  at  the  cost  of  the  organs, 
arrests   the   development  of   the  uterine 
growth,  or  checks  bleeding,  then  the  sur- 
geon  may  rightfully  remove  the  ovaries. 
But  that  the  neurotic  or  mental  conditions 
justifying  such  an   operation  are  exceed- 
ingly rare  is  evident  from  the  fact  that, 
since    1878,  I    have    only   met    with   8 
patients  to  whom  I  could  recommend  the 
operation.    One  of  these  refused  to  the  last 
the  chance  of  relief  from  surgery,  although 
it  was  urged  upon  her  both  by  Battey. 
Marion  Sims,  and  by  me.     Four  opera- 
tions were  purely  Battey's.     The  first  of 
these  was  reported  in  the  Transactions  of 
the  American  Gynrccolo^^ical  Society  for 
1880.     The  patient  was  in  her  50th  year 
and  had  never  been  pregnant.    Her  history 
was  that  of  14  years'  suffering,  with  every 
kind  of  experimental  treatment.     There 
was  association   of  severe  suffering  Avith 
pre-menstrnal    congestion,  justifying    the 
belief  that  ovariotomy,  performed  with  the 
view  of  anticipating  the  climacteric,  would 
be   a    legitimate    proceeding.      We    had 
deferred  the  operation   in  the  hope  that 
at   the   age  of  49   the  catamenia  would 
cease.     But  a   sister,  aged  54,  Avas  still 
menstruating  regularly ;  and  the  patient 
felt  that  it  would  be  impossible  for  her 
to    go   through    4  or    5    years   more    of 
such  repeated  suffering.     After  full  con- 
sideration, both    ovaries  were    removed. 
The    patient   was  very   grateful  for    the 
relief  afforded  her.     I  saw  her  in  1884 
quite  well,  there  having  been  no  return 
of   catamenia  since  April   1880.        The 
recurrence  a  few  times  after  the  opera- 
tion is  explained  by  the  difficulty  I  had  in 
removing  every  fragment  of  the  left  ovary. 
I  mav  quote  here  the  conclusions  which 
I  drew  from  a  consideration  of  this  case : 
*  If  I  meet  with  what  I  believe  to  be  a 
suitable   case,    and   a  willing   patient,   I 
shall  certainly  do  this  operation  again  ; 
removing  both  ovaries,  and  being  especi- 
ally careful  that  every  fragment  of  both 
ovaries    is    removed.      I    should    operate 
rather  through  the  abdominal  wall  than 
by  the  vagina ;  and  be  prepared  for  the 
probability  of  intestines  being  wounded 
when  dividing  the  peritoneum.     In  uniting 
the  edges  of  the  wound,  I  should  place  the 
sutures  nearer  to  each  other  than  is  usual 
in  ordinary  ovariotomy,  in  order  to  guard 
afTainst  the  occurrence  of  a  ventral  hernia.' 
I   still   adhere   to   these   conclusions.      I 
think  it  would  be  only  in  an  exceptional 


case,   where  an  ovary  could  be  felt  low 
down  between  the  vagina  and  the  rectum, 
that  a  surgeon  would  now  do  oophorec- 
tomy through  the  vagina.     In  almost  all 
cases  the  abdominal  operation  would  be 
preferred,  and  a  word  of  caution  is  neces- 
sary to  anyone  about  to  perform  it  under 
the  impression  that  it  is  very  facile  in 
execution ;    for  it  is  more  difficult  than 
ordinary  ovariotomy.      It  is  not  as  easy 
to  divide  the  peritoneum  without  injury 
to  the  intestines.     They  have  a  greater 
tendency   to    protrusion,   and   cannot   be 
replaced  readily  after  they  have  protruded. 
The  opening  into  the  abdomen  should  be 
made  large  enough  to  admit  two  fingers. 
With  these  the  uterus  is  to  be  felt ;   one 
finger  being  in  front  of  the  fundus  and  one 
behind  it.     Then,  by  carrying  them  out- 
wards, first  on  one  side  and  then  on  the 
other,  an  ovary  is  felt  and  may  be  brought 
up  outside  the  abdominal  wall.     Its  con- 
nections with   the  uterus    are  transfixed 
and  tied  in  two  parts  with  a  silk  ligature ; 
a  third  ligature  being  placed  behind  the 
other  two.      The  ends   of   all   must   be 
snipped  off  close  to   the  knots,   and  the 
ovary  cut  away  not  too  near  the  ligatures, 
which  are  then  alloAved  to  slip  down  into 
the  pelvis.     It  is  not  yet  decided  if  the 
fimbria  and  part  of  the  Fallopian  tube 
had  better  be   lemoved  with  the  ovary. 
If  not  quite  healthy,  they  should  certainly 
be  removed.      After  the  second  ovary  has 
been  removed,  the  wound  must  be  closed 
as  usual  after  ovariotomy,  but  Avith  the 
sutures  nearer  to  each  other,  to  obviate 
the    greater    tendency    of   omentum    or 
intestines  to  separate  the  lips  of  the  in- 
cision.    The  tension  is  ahvays  greater  in 
these   cases    than   after   removing   large 
ovarian  tumours,  Avhere  the  integuments 
have  been   a  long    time  on  the   stretch. 
The  dressing  and  after  treatment  should 
be  precisely  the  same  as  for  a  case  of 
ovariotomy. 

Between  January  1878,  the  date  of 
this  first  case,  and  November  1881,  or 
nearly  4  years,  I  did  not  repeat  this  ope- 
ration, and  I  had  only  advised  it  in  one 
other  case,  that  lady  not  being  willing  to 
submit  to  it.  The  lady  on  whom  I  ope- 
rated in  November  1881  Avas  a  AvidoAv,  37 
years  of  age.  She  had  suffered  excessively 
for  about  1 8  months  from  the  pressure  of 
a  hard  pelvic  tumour,  Avhich  obstructed 
the  rectum  and  caused  great  agony  and 
daiiger  at  each  catamenial  period.  At  the 
operation  the  tumour  was  found  to  consist 


OOPHORECTOMY — OR  BATTEY'S   OPERATION 


]2T 


partly  of  tlie  right  ovary,  not  mucli  en-  I 
larged,  and   p:irtly  of  the   thickened  and 
retroflexed  fundus  uteri,  which  I  was  able, 
but  with  great  difficulty,  to  draw  up  above 
the  brim  of  the  pelvis.     I  removed  the 
right  ovary,   the  left  was  atrophied,  and 
so  closely  applied  to  the  side  of  the  uterus 
that  I  could  not  distinguish  its  outlines, 
and  did  not  disturb  it.     The  patient  made 
a  recovery  Avithout  any  fever,  and  in  the 
summer  of  1884  was  quite  well,  having 
menstruated  regularly  since  the  operation, 
at  3  weeks'  interval,  Avithout  any  incon- 
venience.    Here,  of  course,  it  is  doubt- 
ful how  far  the  relief  is  due  to  removal  of 
one  ovary,  or  to  the  reposition  of  the  dis- 
placed viterus.     Neither  in  my  own  ope- 
rative practice,  nor  in  consultation  with 
others,  have  I  seen  more  than  4  patients 
since  November   1881,  to  Avhom  I  have 
advised  ouphorectomy,  or  the  removal  of 
ovaries  not  distinctly  enlarged,  on  account 
of  neurotic  or  neurasthenic  symptoms,  or 
of    dysmenorrhoeal  suffering.      In  one  of 
these  cases  the  operation  was  performed 
by  a  provincial  surgeon.    Another  patient 
is  a  ward  in  Chancery,  and  legal  obstacles 
have  led  to  postponement.  I  performed  the 
operation  on  the  third  patient  in  October 
1882,  removing  the  right  ovary  and  the 
Fallopian  tube.     The  left  ovary  had  been 
removed  in  March  of  the  same  year  in 
Paris  by  Pean,  who  wrote  to  me  that  he 
found  it  in  a  condition  which  he  described 
as  '  Kystique,  liypertropliique  et  cicatriciel 
tres  prononceJ'     The  right  ovary  was,  he 
said,  '  a  peu-pres  normal,^  and  was  therefore 
not  removed.      The   history  of  the  case 
before  Pean's  operation  is  that  of  an  ex- 
tremely sensitive,  excitable,  clever  woman, 
unmarried,  who,  between  her    20th  and 
30th  year,  was  occasionally  treated  by  Dr. 
Oldham  for  irregular   menstruation,  but 
did  not  suffer  much  pain  at  her  periods 
until  her  30th  year.     Then  followed  10 
years  of  invalid  life,  with  great  pain  at 
her  periods.    An  operation  in  1879,  Avhen 
her  age  was  37,  was  done  by  Mr.  Heath 
for  internal  piles.     In  1880,  Dr.  IMeadows 
and   Dr.    Graily  HcAvitt   treated    her  for 
enlargement  of  the  left  ovary.     This  was 
followed  by  enfeebled  general  health  and 
increase  of  pain,  with  failing  nerve  power. 
In  1881,  3  months'  trial  of  electric  cur- 
rent and  German  baths  gave  no  relief; 
until    physical    and   mental    prostration, 
with  recurring  ideas  of  suicide,  led  Dr. 
Pratt,  of  Paris,  to  recommend  the  opera- 
tion, which  was  performed  by  Pean,  as  I 


have   just    said,  in    March    18S2.      The 
patient  rapidly  recovered  from  the  opera- 
tion.    The  wound  healed  by  first  inten- 
tion.    She  Avalked  on  the  18th  day,  but 
on  the  23rd  day  menstruation   returned 
with   excessive  suffering  and  high  fever, 
and  she  was  considered  in  great  danger 
for  more  than  8  days.     She  returned  to 
England  in  May,  9  weeks  after  the  opera- 
tion, and  consulted  Dr.  Oldham  and  Dr. 
Herman  AVeber.    As  her  distressing  sym- 
ptoms increased  to  an  alarming  extent,  her 
menstrual  periods  being  regular,  with  the 
pain  and  the  mental  depression  invariably 
aggravated  at  the  periods,  she  consulted 
Dr.    Playfair,    who    sent   her    to    me.     I 
operated     on    October    10,    1882.      Mr. 
Meredith    assisted    me.       Dr.    Allan,    of 
Cleveland,  U.   S.,    and   Dr.    Fontana,   of 
Zurich,  were  present.     I  made  an  incision 
^  an  inch  to  the  right  of  the  cicatrix  left 
by    Pean's    operation.      After    separating 
omentum,  which  adhered  along  the  whole 
line  of  union,  I  drew  up  the  right  ovary, 
transfixed    the    broad    ligament    with    a 
double  ligature,  and  after  tying  the  liga- 
ment in  two  parts,  cut  away  the  ovary. 
As  the  Fallopian  tube  was  very  red,  tor- 
tuous, and  irregularly  though  slightly  di- 
lated, I  put  another  ligature    round  the 
tube,  about  2  inches  from  the  fimbria;,  and 
cut  away  all  beyond  the  ligature.     I  then 
separated  all  the  omentum  which  adhered 
on   either  side  of  the  united  incision  of 
Pean's  operation,  puttifig  2  ligatures  upon 
omental  vessels.    The  wound  in  the  abdo- 
minal wall  was  closed  in  the  usual  manner. 
The  whole  proceeding  was  completed  in 
less  than  half  an  hour.    The  ovary  removed 
was  about  3  times  the  normal  size,  and 
contained  cystlike  cavities,  one  as  large  as  a 
chestnut.    The  patient  recovered  without 
trouble  of  any  kind,  went  to  Brighton  3 
weeks  after  the  operation,  and  I  have  re- 
ceived most  grateful  letters  from  her  since. 
She  called  on  me  in  December  1884,  saying 
that  there  had  never  been  any  return  of 
menstruation  since  the  operation,  and  that 
in  spite  of  unfavourable  surroundings  and 
family   trouble,    she    Avas    perfectly  well. 
She  mentioned  a  curious  fact,  Avhich  other 
patients  who  have  recoA'ered  after  ovario- 
tomy have  also   observed — that  her  hair, 
Avhich  she  had  almost  entirely  lost  during 
her  illness,  had  groAvn  luxuriantly  since 
the  operation ;  and  I  noticed  that  it  was 
fine,  abmidant,  and  Avithout  a  tinge  of  grey. 
I   operated    on   the  '1th    patient  Au- 
gust 26,  1884,  at  Amsterdam.     She  Avas 


128 


0^'ARIAN   AND   ALLIED   TUMOURS 


Tinmarrled,  25    years  old,  and  since  her 
17th  year  had  suffered  excessively  from 
pain  in  the  right  side   of  the  abdomen. 
After  a  great  variety  of  medical  treatment, 
Professor  Simon  Thomas,  of  Ley  den,  at 
the  suggestion  of  her   usual  medical  at- 
tendant, Dr.  Van  Geuns,  took  away  the 
right  ovary  in  September  1878.    The  pains 
on  the  right  side  disappeared,  but  recurred 
so  severely  on  the  left  side,  that  in  Sep- 
tember   1879,  Professor    Simon    Thomas 
removed  the  left  ovary,  but  without  good 
result.     He  did  not  remove  either  Fal- 
lopian tube.     Menstruation  recurred,  and 
the  pains  became  worse.     In  September 
1880,  Dr.  Berns  opened  the  abdomen  for 
the  third  time,  hoping  that  it  might  be 
possible  to  remove  a  tumour  which  it  was 
thought  could  be  felt  on  the  left  side  of 
the   uterus.      There   were,    however,    so 
many  adhesions  that  he  desisted,  and  closed 
the  woimd.     During  all  these  years  the 
patient  was  always  in  bed,  every  movement 
causing  a  great  increase  of  pain.    In  1883 
Marion  Sims  went  to  Amsterdam  to  see 
her.     He  thought  the  tumour  on  the  left 
side  of  the  uterus  was  the  cause  of  the 
suffering.    Being  obliged  to  go  to  America, 
he  would  not  operate  then,  but  promised 
to  do  so  on  his  return  to  Europe.     His 
death  greatly  distressed  the   patient,  and 
led  to  my  being  consulted.      She  and  her 
iamily,  as  well  as  Dr.  Van  Geuns,  were  so 
anxious  that  some  attempt  to  relieve  her 
continual  sufferings  should  be  made,  and 
the  habit  of  daily  repeated  subcutaneous 
injections  of  morphia  should  be  broken, 
that,  although  I  was  unable  to  feel  any 
tumour  on  either  side  of  the  uterus,  I  con- 
sented to  open  the  abdomen  for  the  fourth 
time,  and  did  so  to  the  left  of  the  central 
cicatrix.     The  cicatrix  of  the  second  ope- 
ration was  still  nearer    to  the  left  ilium. 
I  only  divided  the  peritoneum  far  enough 
to  admit  two  fingers.     This  enabled  me  to 
feel  that  the  rxterus  was  of  normal  size, 
movable,  with  no  tumour  on  either  side 
of  it,  but  that  a  piece  of  omentum  adhered 
both  to  tiie  fundus  uteri  and  the  cicatrix 
to  the  extreme  left,  and  that  a  coil  of  small 
intestine  also  adhered  both  to  the  uterus 
and  the  omentum.     These  I  separated,  but 
did  notliing  more,  and  closed  the  wound. 
I  could  not  find  any  trace  of  either  ovary. 
The  wound  healed  by  first  intention,  and 
recovery  took    place  without   any  fever. 
There  have  been  three  menstrual  periods 
since  th(^  operation,  with  diminisliingpain. 
Very  much  sinuUer  quantities  of  morphia 


have  been  injected,  and  Dr.  Van  Geuns 
sends  a  very  hopeful  report  of  continued 
improvement. 

Since  the  printing  of  this  edition  was 
begun  I  have  removed  both  ovaries  from 
a  married  lady,  a  patient  of  Dr.  Lendon 
of  Notting  Hill,  under  very  peculiar  cir- 
cumstances. She  has  2  living  children ; 
one,  born  alive,  is  noAv  dead.  After 
each  confinement  she  suffered  from  puer- 
peral mania  ;  and  once  the  consequences 
were  tragically  distressing.  Dysmenor- 
rhoeal  suffering  was  also  very  great. 
Partly  to  prevent  this,  and  partly  to 
avert  another  pregnancy,  after  some 
hesitation  and  careful  consultation,  I 
removed  both  ovaries  on  January  27, 
1885.  There  was  no  difficulty  in  the 
operation,  and  recovery  followed  without 
pain  or  fever.  It  is,  of  course,  too  soon 
to  say  more  as  to  the  ultimate  result. 

The  removal  of  the  ovaries  Avith  the 
hope  of  influencing  uterine  growths  will 
be  further  considered  in  the  chapter  on 
these  tumours.  But  I  cannot  conclude 
this  chapter  without  a  word  of  caution 
against  the  extreme  frequency  with  which 
the  operation  has  been  resorted  to  in  this 
country,  and  at  which  Dr.  Battey  publiclv 
expressed  his  astonishment,  at  the  meeting 
of  the  Medical  Congress  in  Loudon.  Many 
cases  where  the  symptoms  have  been  de- 
scribed as  sleeplessness,  hysteria,  nerve 
prostration,  dysmenorrhoea  or  '  neuras- 
thenic disorder,'  have  led  to  Battey's  ope- 
ration, and  in  the  majority  of  such  cases 
healthy  ovaries  have  been  removed.  These 
are  just  the  cases  in  which  Dr.  Weir 
Mitchell's  systematic  treatment,  so  success- 
fully followed  in  this  country  by  Dr.  Play- 
fair,  should  surely  have  been  tried.  Dr. 
Playfair  says,  '  If  a  case  is  purely  neuras- 
thenic it  cannot  under  any  conditions,  I 
apprehend,  be  one  even  for  the  considera- 
tion of  Oophorectomy.  If,  on  the  other 
hand,  there  exist  those  chronic  organic 
changes  in  the  ovaries  which  afford  the 
most  justifiable  ground  for  this  operation, 
any  attempt  at  their  cure  by  this  treatment 
will  inevitably  fail.'  Except  in  cases  where 
bleeding  fibroids  may  call  for  the  removal 
of  the  healthy  ovaries,  or  where  some  such 
reason  arises  for  preventing  future  preg- 
nancy as  that  in  the  case  just  related,  we 
ought  at  least  to  require  some  evidence  of 
the  ovaries  being  diseased  before  consenting 
to  their  extirpation  in  the  hope  of  curing 
any  of  those  vague  nervous  disorders  to 
which  women  are  so  subject,  which  are 


OOPHORECTOMY — OR  BATTEY  S  OPERATION 


129 


often  dispelled  by  moral  treatment  or  social 
changes,  are  often  benefited  by  measures 
that  can  have  but  little  effect  except  on 
the  imagination,  often  return  after  appa- 
rent cure  in  any  way,  and  leave  the 
hapless  beings  tlie  prey  of  unscrupulous 
or  illogically  enthusiastic  experimenters. 

In  a  paper  read  at  the  Medical  and 
Chirurgical  Society  in  1882,  on  hernia  of 
the  ovary,  Dr.  Barnes  contended  that  this 
condition  furnishes  a  legitimate  motive 
for  Battey's  operation.  He  related  a  case 
in  which  an  ovary,  accompanying  a  hernia 
in  the  left  groin,  had  been  removed  from 
one  of  his  jDatients  in  St.  George's  Hos- 
pital. In  the  discussion  which  followed 
Mr.  Hulke  alluded  to  the  comparative 
frequency  of  this  form  of  hernia,  and 
cited  a  case,  under  the  care  of  Mr.  Law- 
son  some  years  ago,  in  which  the  suffering 
was  so  great  that  at  the  wish  of  the  patient 
the  organ  was  extirpated.  Mr.  Langton 
also  showed,  from  his  own  experience  of 
20  years  at  the  Truss  Society,  that  out  of 
4,084  cases  of  inguinal  hernia  no  less 
than  67  were  instances  of  these  displaced 
ovaries.  Forty-two  of  the  67  were  con- 
genital and  25  acquired.  Those  which 
were  congenital  were  generally  double, 
most  of  them  Avere  irreducible,  and  the 
effects  with  regard  to  the  menstrual 
periods  varied  very  much.  Dr.  Barnes 
attributed  the  larger  number  being  on 
the  lelt  side,  to  the  greater  length  and 
laxity  of  the  left  round  ligament,  and  the 
greater  depth  of  Douglas's  pouch  on  the 
left  than  on  the  right  side  ;  and  said  that 
in  this  way  other  pathological  conditions 
more  frequently  observed  on  the  left  than 
on  the  right  side,  such  as  haamatocele, 
might  be  accounted  for.  He  was  of  opi- 
nion that  whei'e  there  was  pain  and  distress 
it  was  better  tu  remove  the  hernial  ovary, 
which  was  liable  to  become  inflamed  and 
diseased,  while  trusses  were  apt  to  cause 
distress. 

At  the  Meeting  of  the  Medico-Chirur- 
gical  Society  of  Edinburgh,  November  7, 
1883,  Dr.  MacGillivray  showed  an  ovary 
and  a  Fallopian  tube  which  he  had  removed 
from  an  inguinal  hernia  in  a  girl  about  20 
years  of  age.  And  at  the  same  Society 
Professor  Chiene  showed  an  ovary  and 
part  of  a  Fallopian  tube  which  he  took 
away  from  the  inguinal  region  of  a  child 
only  3  months  old. 

It  is  somewhat  curious  that  in  all 
my  practice  I  have  never  met  with  a  case 
of  hernia  of  the  ovary. 


The  last  reports  which  I  have  respect, 
ing  Battey's  operation  are  those  to  be 
found  in  Professor  Agnew's  '  Surgery,' 
published  in  Philadelphia.  He  mentions 
107  cases,  of  which  88  were  complete 
I  double  operations.  Sixty-seven  recovered 
:  and  21  died,  a  mortality  of  23'86  per  cent. 
In  all,  he  gives  the  figures  of  171  cases; 
144  by  abdominal  section,  with  a  loss  of 
27,  and  27  vaginal,  of  which  .">  died. 

In  the  '  Ingleby  Lectures'  for  1881, 
Dr.  Savage,  of  Birmingham,  said  that, 
while  Battey,  from  all  the  information  he 
could  obtain,  found  the  mortality  to  be 
about  18  per  cent.,  in  his  own  (Dr. 
Savage's)  practice  he  had  '  had  40  com- 
plete cases,  with  a  result  that  all  have 
recovered  from  the  operation,  and  I 
believe  that  nearly  every  one  has  been 
cured  of  the  disorder  for  which  the 
operation  was  undertaken '  (p.  33). 
Writing  again,  December  5,  1884,  he 
says,  '  My  figures  are  as  follows  up  to 
this  date : 

Removal  of  the  Uterine  Appendages 

For  Mj-oma  ....  37  with  1  death  from  Tetanus 
„    Hydrosalpinx     .10     „    1     „ 
,,    Pyosalpinx     .     .     6     „     1     ,, 
„    Chronic  Ovaritis  V 
„    Dysmenorrhoea,   [r^-.  „ 

and  Neuralgic  [  "  " 

Symptoms,  &c.  ■' 


Total 


134  cases  with  6  deaths. 


Dr.  Savage  removes  both  ovary  and 
Fallopian  tube,  but  he  appears  to  agree 
with  me  in  the  impression  that  liga- 
ture of  the  spermatic  artery  has  more 
to  do  with  the  cessation  of  menstruation 
after  operation  than  the  removal  of  the 
tube  itself. 

Dr.  Fehling,  of  Stuttgart,  contributes 
to  the  'Archiv.  fur  Gynakologie  '  (Band 
xxii.  Heft  3)  an  interesting  article  on  the 
'  Castration  of  Women.'  He  relates  10 
cases,  and  then  expresses  opinions  based 
upon  these  and  upon  other  recorded 
cases.  As  to  mortality,  this  will  di- 
minish. Hitherto  it  has  been  about  10 
per  cent.,  but  he  thinks  with  our  pre- 
sent experience  it  is  not  likely  in  the 
future  to  exceed  at  most  5  per  cent. 
Next  as  to  the  effect  upon  menstruation. 
In  4  cases  out  of  9  he  found  the  meno- 
pause immediately  follow.  The  same 
happened  in  4  cases  out  of  10  published 
by  Tautfer,  and  in  31  out  of  41  recorded 
by  Hegar.  Irregular  hcemorrhages  for  a 
time  followed  by  complete  cessation 
resulted  in  3  of  our  author's  9,  in  3  of 


130 


OVARIAN  AND  ALLIED  TUMOURS 


Tauffer's  10,  in  8  of  Hegar's  41. 
Hsemorrhage  continued  to  recur  for  a 
long  period  (2  years  or  more)  after 
operation  in  2  of  Fehling's  cases,  3  of 
Tauffer's,  and  1  of  Hegar's.  The  results 
of  other  operators  give  similar  figures. 
He  then  considers  the  effect  in  different 
classes  of  cases.  In  cases  of  uterine 
fibroids  the  results  are  excellent.  In  5 
out  of  6  cases  of  his  own  in  which  spay- 
ing was  performed  for  fibroids,  the  meno- 
pause followed.  In  21  similar  cases  of 
Hegar's,  3  died.  The  menopause  fol- 
lowed immediately  in  11,  gradually  in 
6 ;  in  only  1  did  hajmorrhase  persist. 
Fehling  removed  the  ovaries  for  ovarian 
neuralgia  in  1  case  only ;  relief  was 
slow  but  complete.  In  nervous  and 
mental  diseases  he  finds  the  results  are 
not  good ;  even  when  benefited  for  a 
time,  symptoms  return.  Goodell's  pro- 
.  posal,  that  all  insane  women  ought  to  be 


spayed,  Dr.  Fehling  rejects  absolutely. 
He  quotes  Liebermeister  to  the  effect 
that  in  hysteria,  unaccompanied  with 
local  disease,  castration  ought  not  to  be 
performed.  He  does  not  think  it  neces- 
sary, even  if  possible,  to  feel  the  ovaries 
before  commencing  the  operation.  He 
has  not  observed  any  loss  of  sexual 
feeling  as  a  result  of  the  operation. 

The  Samaritan  Hospital  register  shows 
no  otjphorectomies  until  December,  1880, 
from  which  date  up  till  December,  1884 
— i.e.  exactly  four  years — the  number 
recorded  reaches  20.  Of  these  15  were 
for  fibro-myoma  with  menorrhagia,  and  1 
of  them  proved  fatal.  The  remaining  5 
were  for  dysmenorrhoea,  and  all  reco- 
vered. Bantock  operated  8  times,  and 
Thornton  12.  Two  cases  recorded  by 
Meredith  were  not  patients  in  the  Sama- 
ritan, but  in  the  New  Hospital  for 
Women  in  Marylebone  Road. 


CHAPTER   XV 


EESULTS  OF  OVARIOTOMY.   SUBSEQUENT  HISTORY  OF  PATIENTS  WHO  RECOVERED 


The  fact  that  of  1,139  who  have  had  one 
or  both  ovaries  removed  by  me,  891  have 
recovered  from  the  operation,  is  alone 
sufficient  to  justif}'^  the  principle  of  the 
operation,  and  to  prove  that  the  mortality 
— namely,  21*7  per  cent,  on  the  whole 
number,  but  which  has  fallen  from  34  in 
the  first  100  to  11  in  the  last — is 
smaller  than  that  of  many  capital  opera- 
tions which  are  constantly  performed  with- 
out hesitation  in  suitable  cases.  And  this 
mortality  has  of  late  become  so  small, 
death  scarcely  ever  occurring  except  in 
cases  known  before  operation  to  be  unfa- 
vourable ;  while  recovery  is  secured  In 
almost  every  favourable  case,  that  (exclud- 
ing septicaemia)  we  may  confidently  cal- 
culate upon  an  average  death-rate  of  not 
more  than  3  or  4  per  cent.  And  when 
we  consider  that  a  patient  from  whom  one 
ovary  has  been  removed  can  scarcely  be 
said  to  be  mutilated ;  as  she  is  perfectly 
capable  of  fulfilling  all  the  duties  of  a 
wife  and  mother,  menstruating  regularly, 
and  bearing  children  of  both  sexes,  witli- 
out  any  unusual  suffering  either  during 
pregnancy  or  labour  ;  ovariotomy  ought  to 
be  accepted  as  a  more  certain  means  of 


saving  life  from  threatened  death,  restor- 
ing the  sufferer  to  perfect  health,  and 
rendering  her  apt  for  all  the  require- 
ments of  daily  life,  with  a  smaller  risk 
than  almost  any  other  serious  surgical 
operation. 

Fears  have  been  expressed  that  when 
a  patient  recovered  after  ovariotomy  she 
would  in  some  way  or  other  suffer  in  after 
life,  that  she  would  not  menstruate  regu- 
larly— that,  if  she  married,  she  would  not 
have  children,  or  have  children  of  only 
one  sex — that  she  would  become  exces- 
sively fat,  or  lose  her  feminine  appear- 
ance and  her  sexual  instinct — or  that  her 
life  might  be  shortened  by  some  disease 
originating  in  the  operation,  or  by  the 
effects  either  Tipon  some  bodily  organ  or 
upon  the  mind.  In  order  to  ascertain 
how  far  any  of  these  fears  were  well 
founded,  or  were  exaggerated,  or  were 
purely  imaginary  and  destitute  of  founda- 
tion, I  asked  every  patient  who  recovered 
to  write  to  me  once  every  year,  on  the 
anniversary  [of  the  operation,  giving  me 
full  information  as  to  her  state.  Nearly 
all  pi'omised  compliance,  and  a  few  have 
written     several     years     in     sutcession. 


RESULTS   OF  OVATIIOTOMY 


131 


Many  have  written  once  or  twice,  some  I 
have  occasionally  seen,  but  there  were  so 
many  of  whom  I  heard  nothing  that  in 
May  and  June,  1872,  and  at  the  latter 
end  of  1881,  I  sent  a  circular  to  every 
patient  who  had  recovered  after  ovario- 
tomy in  my  practice,  or  to  the  medical 
friend  by  whom  she  was  sent  to  me, 
asking  for  information  on  the  following 
points,  and  in  this  form  : 

Name  of  patient. 
Date  of  operation. 
Present  state  of  liealtli. 
If  married  since — when  ? 
Is  husband  still  alive  ? 
If  any  children — 

Date  of  births. 

Sex  of  children. 
Anything  unusual  in — 

Pregnancy, 

Or  labour. 
If  dead,  cause  and  date  of  death. 
Any   other  information   connected   with   the 

operation  or  the  patient  which  may  seem 

important. 

ISignatiire . 

Date 

From  circulars  returned  to  me,  and 
from  other  sources,  I  am  able  to  say  that 
of  the  1,000  women  who  submitted  to 
ovariotomy  by  me  between  February 
1858  and  June  1880  : 

449  reported  themselves  well  in 

1881. 
11  were  well  in  1880,  and  have 

not  been  heard  of  since. 
86  were  well  in  1872  and  have 

since  made  no  report. 
55    have    reported    themselves 

well     within     the    last    10 

years     without     answering 

my  last  letter  in  1881. 
50  have    made    no    report    of 

themselves   since    the    ope- 
ration : 


651 


Making  651  either  alive  or  not  known  to 
be  dead. 
127  died    after  operation  among 

the  first  500. 
105  died   after  operation  among 

the  second  500. 
117  died  since   recovering   from 

the  operation. 

1,000 

Of  the   117  deaths  since  recovery  from 
operation : 

29  died  without  cause  assigned. 
43  died  of  diseases  of  the  brain, 


heart,    or   lungs,  quite   un- 
connected with  the  operation. 
7  died     of    diseases    of    the 
abdominal  or  pelvic  organs. 
32  died  of  malignant  disease  of 
various  parts. 
6  died  of  return  of  the  ovarian 
disease. 


117 


Of  the  1,000  women  operated  on  : 

439  who   were  married  at  the  time 
recovered  from  the  operation. 
70  of  these  have  since  given  birth 

to  126  children. 
36  have  had  one  child  (1  still- 
born) =  36 
18  have  had  2  children   (one 

twins  stillborn)  =36 

11  have  had  3  ,,         (one 

twins)  =33 

4  have  had  4  „  =16 

1  has  had  5  ,,  =:  5 


126 


1  woman  has  had  triplets. 
4  women   have    been   married    a 
second   time ;    one  having  two 
children  by  her  second  husband. 
369  have  remained  sterile. 
329    women    unmarried   at  the  time    of 
operation  recovered. 
70  of  these  have  since  married. 

1  woman  has  been  married  three 
times. 

44  of  these  married  women   have 
given  birth  to  99  children. 

18  married  women  have,  since 
operation,  had  1  child  (1 
stillborn)  =18 

11  married  women  have  had 
2  children  (one  twins)         =22 

10  married  women  have  had  3 

children  =30 

2  married  women  have  had  5 
children  (3  stillborn)  =10 

2  married  women  have  had  6 
children  =12 

1  married  woman  has  had  7 
children  =  7 


99 
3  single  women  have  had  1  child        =  3 

Making  a  total  of  228  children  born 
amongst  117  women  after  their  recovery 
from  ovariotomy. 

K  2 


132 


OVARTAX   AND    ALLIED   TUMOURS 


lilany  in  writing  the  report  add  that  j 
they  are  well  and  strong,  or  better  than 
they  have  been  for  many  years,  or  some 
such  phrase,  expressive  of  their  complete 
restoration.  A  few  complain  of  some 
trilling  ailment.  I  know  that  a  large 
proportion  of  those  who  filled  up  the 
returns  in  1881  are  still  alive  and  well, 
and  that  other  children  have  been  born 
since ;  but  as  only  3  years  have 
elapsed,  1  have  not  issued  fresh  circulars. 

I  have  not  been  able  to  trace  any 
peculiarity  in  the  subseqi;ent  condition  of 
patients  who  have  recovered  after  removal 
of  both  ovaries  as  compared  with  those 
from  whom  only  one  was  removed, 
except  that,  with  only  three  exceptions, 
there  has  not  been  menstruation  after 
recovery.  One  young  unmarried  woman 
became  very  florid  and  stout ;  but  I  have 
seen  nothing  like  the  excessive  corpulence 
anticipated  by  those  whose  expectations 
were  based  on  the  effect  of  castrating 
domesticated  animals. 

1  have  ascertained  from  the  husband 
or  medical  attendant  of  some  of  my  own 
patients,  that  sexual  desire  and  gratifica- 
tion have  certainly  not  been  less  than 
before  operation.  In  some  cases,  where 
only  one  ovary  was  removed,  desire  had 
been  increased.  One  husband  told  me 
that  his  wife  had  been  remarkably  cold 
before  ovariotomy,  but  was  afterwards 
extremely  amorous. 

To  the  best  of  my  knowledge  this  is 
the  first  time  that  any  such  extended 
inquiry  into  the  subsequent  history  of 
patients  who  have  recovered  froai  a  capital 
operation  has  been  carried  out.  As  a 
rule,  in  all  statistical  returns  from  hos- 
pitals, the  bare  fact  of  death  or  recovery 
is  all  the  information  that  is  given,  and 
any  attempt  to  follow  up  the  successful 
cases  afterwards  is  found  to  be  excessively 
difficult.  Some  years  ago,  I  endeavoured 
to  ascertain  what  became  of  patients  who 
recovered  after  amputation  of  the  tliigh. 
I  had  good  reason  for  believing  that  many 
died  within  a  year,  but  was  never  able  to 
obtain  anything  like  correct  statistical 
information.  The  hospital  reporters  of 
the  *  Lancet '  once  collected  together  par- 
ticulars of  all  the  cases  in  which  amputa- 
tion at  the  hip-joint  had  been  performed 
for  several  years  in  London  liospitals.  A 
large  proportion  of  the  patients  died 
within  a  day  or  two  of  the  operation, 
and  of  those  who  recovered  the  only  one 
alive  a  year  after  operation  was  a  woman 


whose  thigh  I  removed  at  the  hip-joint, 
in  the  Samaritan  Hospital,  on  account  of 
malignant  disease.  It  is  well  known  that 
patients  who  have  been  cured  of  aneu- 
rism, either  by  ligature  or  compression, 
are  very  apt  to  suffer  from  the  disease  in 
some  other  artery  ;  but  it  is  left  to  some 
future  inquirer,  or  some  committee  of 
collective  investigation,  to  ascertain  the 
frequency  and  date  of  such  return  of 
disease.  We  have  a  little  more  infor- 
mation as  to  patients  who  undergo  litho- 
tomy a  second  time.  Most  of  the  in- 
formation ends  with  the  immediate  result 
of  the  operation,  and  but  little  is  known 
of  the  subsequent  history  of  the  patient. 
I  hope  that  what  has  been  done  in  thirt 
respect  with  regard  to  ovariotomy,  and 
latterly  by  Sir  H.  Thompson  with  rega/rd 
to  lithotomy  and  lithotrity,  will  not  only 
be  useful  in  enabling  us  to  form  a  correct 
estimate  as  to  the  value  of  these  opera- 
tions, but  will  induce  other  surgeons  to 
obtain  similar  information  as  to  the  sub- 
sequent history  of  patients  who  recover 
after  amputation  of  a  limb,  excision  of  a 
large  joint,  ligature  of  main  arteries, 
herniotomy,  or  trephining. 

When  a  surgeon  has  removed  a  large 
diseased  ovary  and  the  woman  recovers, 
he  has  in  very  many  cases  the  great  satis- 
faction of  feeling  that  his  patient  has  been 
restored  to  perfect  health.  Experience 
has  proved  that  the  remaining  ovary 
generally  carries  on  its  functions,  and 
that  the  woman  may  become  the  mother 
of  healthy  children  of  both  sexes.  The 
patient  is  not  mutilated  as  by  the  amputa- 
tion of  a  limb,  nor  does  the  general  health 
suffer  as  it  frequently  does  after  the 
greater  amputations.  There  certainly  is 
nothing  like  the  tendency  to  recurrence 
Avhicli  there  is  after  the  removal  of  malig- 
nant tumours;  probably  by  no  means 
so  frequent  an  occurrence  of  disease  else- 
where as  after  successful  ligature  of 
a  diseased  artery,  or  disease  of  the 
opposite  lens  after  successful  removal  of 
one  cataract,  or  formation  of  a  second 
calculus  after  a  removal  of  one  by  litho- 
tomy or  lithotrity  ;  and  certainly  no  such 
prolonged  suffering  as  from  the  chronic 
cystitis  which  not  unfrequently  follows 
these  two  operations. 

The  rule  is,  that  by  a  successful 
ovariotomy  the  patient  ia  restored  to  a 
state  of  health  so  perfect  that  she  and  her 
friends  are  as  surprised  as  they  are 
gratified.      But  there  are    exceptions   to 


IIESULTS   OF  OVAKIOTOMY 


.00 


ttliis  rule.  In  some  cases  a  disease  be- 
lieved to  be  innocent  proves  to  be  malig- 
nant, soon  recurs,  and  proves  fatal  within 
a  few  months,  or  even  within  a  few  weeks 
■after  apparent  recovery.  In  other  cases 
the  ovary  which  is  left  untouched  because 
"it  is  believed  to  be  healthy,  or  so  slightly 
•diseased  that  its  removal  is  uncalled  for, 
becomes  the  seat  of  disease.  In  what 
proportion  of  cases  this  occurs  we  have 
•even  now  but  little  more  information 
than  may  be  found  in  this  volume.  It 
is  only  within  the  last  20  years  that  ova- 
riotomy has  been  performed  sufBcieutly 
•often  to  furnish  data  for  reliable  sta- 
tistics, and  it  is  difficult  to  ascertain, 
even  in  some  of  these  later  cases,  what 
has  been  the  state  of  the  patient's  health 
a  few  years  after  operation.  But  it 
would  be  unreasonable  to  expect  that  in 
all  cases  the  ovary  left  in  the  body  would 
remain  healthy.  It  is  for  future  obser- 
vation to  decide  how  often  and  in  what 
class  of  cases  a  recurrence  of  disease  may 
be  feared.     The  fact  that  in  my  practice 


there  were  11  recurrences  requiring  a 
second  operation  out  of  1,139  patients, 
gives  a  proportion  of  1  in  about  every  100 
cases,  and,  so  far  as  I  can  make  out,  the 
character  of  the  cysts  was  generally  pro- 
liferous ;  at  any  rate,  it  Avas  so  in  almost 
all  the  cases  in  Avhich  an  accurate  report 
has  been  kept  of  the  character  of  the 
tumours.  It  is  satisfactory,  however,  to 
learn  that  if  the  remaining  ovary  should 
become  diseased,  the  first  operation  does 
not  add  to  the  difficulty  of  a  second,  and 
tliat  the  second  ovariotomy  has  proved 
successful  in  II  out  of  the  13  cases  in 
which  I  have  operated,  and  in  the  case  in 
which  Atlee  operated  16  years  after  the 
first  operation  by  Clay. 

The  rare  exceptions  to  the  general 
rule  of  complete  restoration  of  health 
cannot  be  considered  as  invalidating  the 
claim  of  ovariotomy  to  be  considered  as 
one  of  the  greatest  of  surgical  triumphs 
— relieving  suffering,  saving  life,  and 
restoring  Avomen  doomed  to  inevitable 
death  to  good  health. 


134 


UTERINE   AND  OTHER  ABDOMINAL   TUMOURS 


PAET    II 
UTERINE    AND    OTHER    ABDOMINAL    TUMOURS 


CHAPTER   I 


UTERINE    TUMOURS 


After  looking  through  much  of  the 
English,  French,  German,  and  American 
literature  of  the  subject  of  uterine 
tumours,  I  may  say  that  in  the  course  of 
my  practice  I  have  met  with,  either 
among  the  cases  upon  which  I  have 
operated,  or  which  have  been  under  my 
treatment,  or  that  I  have  seen  in  con- 
sultation, every  variety  of  fibroid  tumour 
described  or  figured  by  the  Avriters.  I 
have  not  observed  any  special  peculi- 
arities in  the  composition  or  structure  of 
these  tumours,  and  have  always  found 
them  to  consist  of  the  same  histological 
elements.  The  difference  amono:  the 
tumours  has  been  more  that  of  form, 
owing  to  the  way  in  which  those  elements 
have  been  arranged.  The  main  substance 
is  white  fibre  tissue,  merging  on  the  one 
hand  into  the  form  of  unstriped  muscular 
tissue,  on  the  other  into  that  of  connective 
tissue.  The  relative  quantity  of  these 
tissues  varies  in  all  the  tumours,  and 
even  in  the  different  parts  of  the  same 
tumour;  and  according  as  one  or  the 
other  predominates,  so  do  the  remaining 
constituents  become  less  conspicuous.  In 
the  simplest  tumours,  with  little  more 
than  white  fibre,  the  vascular,  nervous,  and 
lymphatic  tissues  are  scanty  ;  while  in  a 
tumour  lobulated.and  intersected  through- 
out without  connective  tissue  septa,  the 
blood-vessels,  lymphatics,  and  nerves  are 
more  abundant.  In  contrast  with  the 
papillomatous  growths  and  cancerous 
degenerations  which  assail  the  uterus, 
they  take  their  origin  from  the  tissue 
cells,  and  are  in  no  way  e])ithelial. 
In  the  section  of  a  simple  fibroid  tumour, 
or  a  lobule  of  a  conglomerate  tumour,  the 
appearance   of    the    distinctive    part    of 


which  it  consists  is  more  like  that  of  in- 
tervertebral fibro-cartilage  than  anything 
else,  unless  it  be  certain  indurated  con- 
ditions of  the  uterine  walls  themselves. 
When  the  tumours  are  small,  and  in 
their  early  stages,  the  fibrous  elements 
have  often  a  concentric  arrangement 
round  a  single  centre,  and  the  same 
distribution  may  be  traced  in  the  nodules 
of  the  larger  conglomerate  masses.  As 
might  be  expected  from  the  abnormal 
character  of  these  neoplasms,  the  histo- 
logical elements  are  generally  imperfectly 
developed,  and  the  less  they  are  developed 
the  more  abundantly  are  nuclei  dispersed 
among  them.  The  condition  of  the  con- 
stituent parts  of  the  tumour,  and  the 
rapidity  and  slowness  of  growth,  depend 
very  much  upon  the  supply  of  blood. 
This  in  some  cases  is  so  small  that  the 
arteries  are  of  diminutive  size,  and 
injections  are  with  difficulty  introduced 
into  the  substance  of  the  tumour,  though 
it  occasionally  happens  that  arteries  large 
enough  to  cause  great  hemorrhage  are 
found  distributing  blood  to  all  parts. 
The  form  of  these  tumours  is  in  almost 
all  cases  at  first  round  or  pear-shaped. 
As  they  enlarge  they  become  modelled 
by  the  parts  with  which  they  come  in 
contact,  and  the  direction  of  their  growth 
is  in  a  measure  influenced  by  the  resist- 
ance which  they  meet  Avith  from  the 
neighbouring  organs.  It  is  seldom  that 
they  are  solitary,  and  where  there  is  a 
tendency  to  their  formation  it  is  common 
to  find  other  growths  of  the  same  kind, 
either  as  offshoots  from  the  parent 
tumour,  or  implanted  on  other  parts  of 
the  same  uterus.  They  are  by  no  means 
uncommon,  though  not  often  formed  at  an 


UTERINE   TUMOURS 


135 


early  time  of  life.  My  experience  leads 
me  to  believe  that  none  of  the  estimates 
of  frequency  during  the  period  of  sexual 
activity  are  exaggerated.  1  should  be 
inclined  to  think  them  quite  as  common 
as  cystic  disease  of  the  ovaries,  perhaps 
more  common,  though  fortunately  neither 
so  detrimental  to  health  nor  so  rapidly 
fatal.  The  frequent,  almost  accidental 
discovery  by  women  of  their  unsuspected 
existence,  and  their  unlooked-for  dis- 
closure in  post-mortem  examinations, 
their  sometimes  temporary  existence  and 
spontaneous  disappearance,  and  the  effect 
of  surgical  treatment  in  causing  their 
diminution  or  inactivity,  all  show  how 
little  prejudicial  is  their  nature,  and  that 
much  of  the  evil  they  cause  is  mechanical. 
As  they  are  for  the  most  part  excrescences 
of  a  fleshy  hollow  organ,  it  is  only  natural 
that  they  should  be  found  on  the  outer 
and  inner  surfaces,  and  sometimes  im- 
bedded in  the  muscular  walls.  In  some 
cases  the  tumour  is  nothing  more  than  a 
symmetrical  overgrowth  of  the  walls  all 
round  the  uterine  cavity,  though  these 
cases  are  seldom  free  from  either  sub- 
peritoneal outgrowths  or  sub-mucous  in- 
growths. The  tumours  growing  either 
on  the  sub-peritoneal  surface  or  projecting 
into  the  uterine  cavity,  although  sessile 
when  growth  commences,  are  often  in 
later  stages  of  grov/th  pedunculated,  and 
receive  their  supply  of  blood  through  the 
pedicle.  Most  hard  growths  originating 
in  the  wall  substance  of  the  iiterus  are 
capsuled.  The  larger  blood-vessels 
ramify  in  the  capsule,  those  entering  the 
growth  itself  being  usually  small.  There 
is  sometimes  a  special  tendency  to  the 
formation  of  cystic  cavities  in  the  interior 
of  these  tumours.  This  cystlike  condition 
has  come  under  my  notice  with  greater 
frequency  than  most  other  writers  have 
recorded.  Sometimes  it  has  seemed  to 
arise  from  a  softening  of  tissue,  especially 
in  that  kind  of  tumour,  first  clearly 
brought  under  notice  by  Barnes,  which  is 
chiefly  seen  in  the  body  of  the  uterus,  and 
is  large,  soft,  of  loose  texture,  without  very 
distinct  capsule,  more  vascular,  often 
oedematous,  less  liable  to  calcareous 
degeneration,  and  generally  the  cause  of 
metrorrhagia.  In  other  cases  their  pro- 
duction has  arisen  from  a  process  of  cyst 
formation,  such  as  that  recognised  in 
cystic  disease  of  the  breast  and  other 
organs.  The  character  of  the  tumour 
depends  very    much   upon   that   of   the 


tissues  of  the  part  of  the  organ  from 
which  it  springs,  and  it  takes  a  solid 
or  looser  form,  according  to  the  density 
or  looseness  of  the  texture  of  the  parent 
layers.  Thus  on  the  outside,  attached  to 
the  cortical  layer  of  the  uterus,  we  find 
the  hard,  unsucculent  tumours,  tenacious 
of  life,  and  lasting  oftentimes  till  old  age, 
even  in  a  condition  of  degeneration.  In 
the  walls  of  the  womb  we  find  the  soft, 
pulpy,  vascular  growths  which  have  a 
tendency  to  inflammatory  action  and 
necrosis  from  injuries ;  and  on  the  mu- 
cous side  of  the  organ  the  quick-growing, 
bleeding  excrescences  which  approach  in 
certain  respects  to  the  hsemorrhagic  con- 
dition of  the  erectile  tumours  occasionally 
found  in  this  situation.  In  the  recurrent 
form  of  fibroid  tumours  generally  growing 
towards  tlie  cavity,  there  is  some  affinity 
with  malignant  disease,  especially  as  to 
its  tendency  to  reproduction  if  removed, 
and  to  secondary  appearance  in  other 
parts  of  the  body. 

Of  size,  I  have  seen  instances  varying 
from  that  of  a  pea  to  some  of  enormous 
bulk  and  weight,  filling  up  all  available 
space  in  the  pelvis  and  abdomen  compa- 
tible with  the  continuance  of  the  organic 
functions,  and  in  one  example  of  successful 
removal  amounting  to  the  weight  of  70 
pounds,  with  a  measurement  of  57  inches 
by  53. 

The  contour  of  the  originally  rounded 
nodules  soon  becomes  modified  by  con- 
tact with  the  hard  parts  of  the  pelvis,  and 
by  the  continued  resistance  of  all  that  it 
meets  in  the  course  of  its  growth.  The 
extension,  of  course,  is  most  rapid  in  the 
direction  where  the  obstacles  are  the  least 
strong,  and  it  would  be  useless  to  attempt 
to  give  an  idea  of  the  strange  forms  pro- 
duced by  external  modelling,  and  the 
varying  degrees  of  nutrition  depending 
iipon  changes  in  the  vascular  condition  ot 
the  interior.  The  external  appearance  of 
the  conglomerate  tumours  is  affected  by 
the  same  causes,  and  they  are  equally 
multiform. 

The  life  history  of  these  structurally 
orthodox  excrescences,  when  not  compli- 
cated by  accident  or  induced  functional 
derangement,  is  simple  enough.  They 
commence  their  existence  at  a  time  when 
the  organ  which  they  affect  is  in  a  state 
of  high  functional  activity,  they  partici- 
pate in  its  periodical  variations,  increase 
with  its  accessions,  slacken  growth  with 
its  torpidity,  and  if  nothing  happens  to 


136 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


check  the  even  tenour  of  their  progress 
they  often  dwindle  away  with  the  cessa- 
tion of  sexual  life,  or  submit  to  one  of 
those  comparatively  innocent  forms  of 
degeneration  which  we  know  as  fatty 
transformation  and  calcification.  This 
petrifaction,  it  must  be  remembered,  has 
no  relation  to  the  organising  tendency  of 
the  process  of  ossification,  but  consists  in 
a  mere  interstitial  deposit  of  calcareous 
matter,  Avhich  replaces  the  living  tissue 
and  remains  a  foreign  body  lodged  in  the 
abdomen  as  a  peritoneal  calculus,  some- 
times to  extreme  old  age.  It  is  the  study 
of  this  life  history  which  has  led  logically 
to  the  modern  surgical  treatment  of  some 
kinds  of  these  tumours,  and  the  amount 
of  success  which  has  attended  it  would 
induce  one  to  hope,  if  not  to  believe,  that 
Avhen  the  physiological  and  pathological 
conditions  attending  the  rise  and  progress 
of  some  other  tumours  have  been  investi- 
gated in  the  same  philosophical  spirit,  and 
with  as  miich  perseverance,  correspond- 
ing means  may  be  found  of  holding  them 
in  check  or  causing  their  suppression. 

But  the  life  of  these  tumours  is 
subject  to  too  many  accidents  and  inter- 
ferences for  this  course  and  teriuination 
to  be  the  rule.  It  is  rather  the  exception, 
as  much  so  as  centenarian  duration  is  in 
human  existence.  Still,  there  are  other 
modes  in  which  early  involution  has  been 
brought  about.  It  has  been  observed 
after  delivery,  and  to  correspond  with  the 
process  of  involution  of  the  womb.  And 
with  the  organ  unimpregnated  I  have 
many  times  noted  the  disappearance  of 
these  tumours,  which,  though  doubted  by 
some,  has  been  well  attested.  It  is  owing 
probably  to  the  arrest  of  nourishment  by 
diminution  of  the  vascular  supply,  and 
the  attendant  retrograde  changes  of  fatty 
degeneration  and  absorption,  or  more  or 
less  continuous  discharge  of  debris  from 
the  uterine  cavity,  after  menstrual  influ- 
ence cnases.  At  any  rate,  the  atrophy  of 
these  tumours  from  time  to  time,  either 
without  interference  or  under  medical 
treatment,  is  a  pathological  fact.  Then 
there  is  another  way  in  which  the  uterus 
rids  itself  of  the  mural  excrescences,  and 
it  is  easy  of  comprehension.  The  pre- 
sence of  the  interstitial  growth  causes 
hypertrophy  of  the  uterine  wall.  Its 
force  is  increased,  and  when  the  pressure 
of  the  growth  lias  gone  on  to  such  an 
extent  as  to  occasion  absorption  of  the 
intervening  substance   and  ulceration   of 


the  mucous  lining,  this  force  may  be 
called  into  action  by  some  occasional 
stimulus,  and  the  expulsive  power  is 
sufficient  to  enucleate  the  whole  mass, 
and  drive  it  out  not  only  from  its  seat, 
but  into  the  uterine  cavity,  or  even  into 
the  vagina.  It  is  doubtful  whether  these 
uterine  fibroid  tumours  ever  undergo  can- 
cerous degeneration.  There  is  no  reason 
why  this  tissue  should  be  exempt  from 
such  a  process,  but  the  records  of  it  are 
so  rare  that  it  is  virtually  regarded  as  a 
termination  not  to  be  looked  for.  There 
is  nothing  known  as  to  the  causes  of  the 
development  of  these  tumours,  and  the 
peculiarities  of  temperament  or  bodily 
constitution  which  give  a  tendency  to 
their  formation  are  not  understood  so 
well  as  the  conditions  which  conduce  to 
their  disappearance. 

In  many  cases  these  tumours  exist  for 
a  long  time  without  being  discovered, 
and  still  more  frequently  they  cause  only 
discomfort  without  injury  to  the  general 
health.  When  bulk  and  weight  increase 
they  produce  the  same  local  symptoms  as 
other  tumours  in  the  same  situation,  but 
still  without  the  same  amount  of  consti- 
tutional derangement.  Yet  when  the 
pressure  becomes  excessive  the  organs 
encroached  upon  must  suffer,  and  the 
symptoms  depend  upon  the  direction  in 
which  the  tumour  is  acting.  There  may 
be  difficulty  with  the  bladder,  and  there 
may  be  pressure  on  one  or  both  ureters, 
and  suspension  of  the  renal  function. 
Nutrition  may  be  arrested,  and  ail  that 
depends  upon  the  proper  action  of  the 
alimentary  canal  may  be  at  fault.  There 
may  be  incessant  variations  of  nervous 
symptoms,  and  in  some  cases  excessive 
pain  from  nerve  pressure.  The  uterine 
troubles  assume  an  infinite  variety  of 
forms,  including  spasmodic  action,  dis- 
charges, and  ha-morrhages,  accompanied 
with  the  well-known  sympathetic  affec- 
tions of  distant  parts  and  responding 
organs.  Of  course  the  symptoms  depend 
much  upon  the  position  and  character  ot 
the  tumour  itself.  Usually  with  the  sub- 
peritoneal tumours  the  haemorrhage  is  not 
much,  but  the  tendency  to  ascites  greater. 
The  sub-mucous  variety,  on  the  contrary, 
is  more  likely  to  be  attended  with  profuse 
bleeding.  And  in  cases  where  the  bleed- 
ing is  not  only  profuse  but  persistent,  we 
may  expect  to  find  the  cause  in  a  tumour, 
probably  of  no  great  size,  of  the  lower 
part  of  the  body  of  the  uterus,  or  of  the 


UTERINE   TUMOURS 


137 


cervix.  The  inter-menslrual  secretions 
are  not  much  affected,  though  sometimes 
leucorrhosal  discharges  become  trouble- 
some. Menstruation  is  more  frequently 
than  otherwise  rendered  difficult  and 
superabundant,  while  in  some  instances 
there  is  a  more  or  less  marked  condition 
of  amenorrho3a.  Fecundity  is  generally 
diminished,  but  conception  is  not  ren- 
dered impossible.  Few  women  with 
these  tumours  have  large  families,  partly 
owing  to  the  predisposition  to  miscarriage 
under  such  circumstances.  But  I  have 
known  several  patients  with  uterine 
tumours  who  have  become  pregnant, 
have  gone  on  to  the  full  term,  and  have 
borne  living  children.  In  some  of  these 
the  tumour  has  disappeared,  more  or  less 
entirely,  within  a  few  weeks  or  months  of 
the  delivery.  In  3  cases  repeated  preg- 
nancies have  occurred  without  much 
change  in  either  the  uterus  or  the 
tumour.  In  one  of  these  the  tumour 
was  so  large  that  it  was  mistaken  at  the 
labour  by  an  experienced  accoucheur, 
after  the  birth  of  the  child,  for  a  second 
child. 

It  is  only  since  ovariotomy  has  be- 
come a  familiar  operation  that  the  fact 
of  uterine  tumours  frequently  attaining 
a  very  large  size  has  become  generally 
known.  Even  now  I  am  often  told  by 
men  of  great  experience  that  a  tumour 
must  be  ovarian  because  it  is  too  large  to 
be  uterine.  They  have  never  seen  nor 
heard  of  any  such  enlargement  of  the 
uterus,  and  are  astonished  when  I  say 
that  the  largest  abdominal  tumours  I  have 
ever  seen  have  been  fibroid  or  fibro- cystic 
tumours  of  the  uterus. 

In  one  of  the  earliest  attempts  to 
perform  ovariotomy  in  Great  Britain, 
in  1825,  Mr.  Lizars  fell  into  this  error 
of  diagnosis.  He  opened  the  abdomen 
and  found  a  large  uterine  tumour.  And 
the  first  tumour  supposed  to  be  ovarian 
which  was  removed  in  London — by  Dr. 
Granville,  in  1827 — proved  to  be  a 
fibroid  tumour  of  the  uterus,  weighing  8 
pounds.  Of  the  8  first  published  cases 
by  Kceberle  of  removal  of  uterine  tu- 
mours by  gastrotomy,  in  only  3  was 
the  diagnosis  of  uterine  tumour  made 
accurately  before  operation.  In  2  the 
diagnosis  was  doubtful,  and  in  3  the 
tumour  was  believed  to  be  ovarian.  In 
fact  it  has  happened  to  many  surgeons, 
and  to  myself  among  the  number,  that  we 
have  commenced  operations  as  ovariotomy, 


and  even  removed  tumours  from  the  abdo- 
men, under  the  impression  that  we  were 
dealing  with  diseased  ovaries,  when,  upon 
examination,  they  have  proved  to  be  pe- 
dunculate fibroid  outgrowths  from  the 
uterus.  At  first,  when  it  was  discovered 
that  a  tumour  was  uterine,  it  was  left 
alone.  Then,  if  pedunculate,  it  was  re- 
moved. It  is  only  of  late  years  that  large 
solid  uterine  groAVths,  not  pedunculate, 
have  been  operated  on  designedly. 

The  revival  of  ovariotomy  between 
1858  and  1865  led,  in  the  words  of 
Paget,  to  '  an  extension  of  the  whole 
domain  of  peritoneal  surgery.'  This 
extension,  naturally  enough,  began  with 
the  removal  of  uterine  tumours. 

In  my  first  work  on  *  Diseases  of  the 
Ovaries,'  published  in  1865,  I  have  re- 
corded cases  where  I  removed  large 
uterine  tumours  containing  solid  fibroid 
masses  many  pounds  in  weight,  and  cyst- 
like cavities  containing  more  than  20 
pints  of  fiuid,  these  tumours  being  so 
far  pedunculated  outgrowths  from  the 
peritoneal  surface  of  the  uterus  that  the 
mobility  of  the  cervix  uteri  was  free,  and 
no  enlargement  of  the  uterine  cavity  could 
be  detected  by  the  sound. 

THE    DIAGNOSIS    OF    UTERINE    FROM  OVARIAN 
TUMOURS 

is  a  difficulty  which  frequently  arises 
in  practice,  which  may  often  be  solved 
wath  great  ease,  which  as  often  requires 
much  cautious  investigation,  and  which  in 
some  cases  can  only  be  cleared  up  by  an 
exploratory  incision. 

It  is  quite  certain  that  both  uterine 
and  ovarian  tumours  may  lead  to  very 
great  enlargement  of  the  abdomen,  and  I 
can  add  from  my  own  experience  that  the 
tumours  may  be  central  in  position,  or 
inclined  to  one  or  other  side;  either  round, 
ovoid,  or  irregular  in  form;  smooth  or 
lobulated  on  their  surface  ;  either  hard, 
or  elastic,  or  fluctuating  ;  either  tender  or 
insensible  to  pressure  ;  and  either  adher- 
ing to  the  abdominal  wall  or  moving 
beneath  it  with  or  without  crepitation. 

It  is  also  certain  that  there  is  nothing 
in  the  history  of  a  doubtful  case  which 
affords  any  very  decisive  assistance  in 
diagnosis;  for,  although  the  increape  of 
ovarian  tumours  is  often  rapid,  it  is  al- 
most as  often  slow ;  and  if  the  increase  of 
uterine  tumours  is  generally  slow,  it  is 
not  unfrequently  rapid.     Uterine  hsemor- 


138 


UTERINE   AND  OTHER  ABDOMINAL  TUMOURS 


rhage,  either  in  tlie  form  of  excessive 
menstruation  or  of  flooding  at  irregular 
intervals,  is  certainly  more  common  in 
uterine  than  in  ovarian  tumours,  but  is 
occasionally  associated  with  the  latter. 
Probably  the  rule  is  that  menstruation  is 
scanty  when  a  tumour  is  ovarian,  and 
excessive  when  it  is  uterine ;  but  excep- 
tions to  this  rule  are  numerous,  and  dis- 
charges of  albuminoid  fluids  from  the 
vagina  at  variable  intervals  are  common 
in  both  classes  of  tumours. 

So  with  the  age  of  the  patient.  Per- 
haps uterine  may  be  more  common  than 
ovarian  tumours  in  old  persons,  and 
ovarian  more  common  than  uterine  tu- 
mours in  young  persons  ;  but  it  is  certain 
that  both  uterine  and  ovarian  tumours  are 
common  in  single,  married,  and  widowed 
women  at  all  ages  after  puberty,  and  in 
all  conditions  of  life. 

Both  are  also  observed  in  some  women 
who  are  extremely  fat,  in  some  who  are 
otherwise  healthy  and  well  nourished,  and 
in  some  who  are  extremely  emaciated ; 
and  there  is  a  facial  expression  common 
to  women  suffering  from  both  classes  of 
tumours,  associated  commonly  Avitli  a 
very  florid  complexion  when  the  tumour 
is  uterine.  In  the  majority  of  ovarian 
cases  the  complexion  is  pallid ;  but  in 
some  cases,  where  the  patient  is  fat  or 
well  nourished,  the  complexion  may  be 
florid. 

Remembering  the  numerous  exceptions 
to  all  the  rules  just  stated,  we  may  now 
inquire  what  may  be  learned  by  the  eye, 
the  touch,  and  the  ear,  in  an  examination 
of  the  abdomen ;  in  other  words,  what 
are  the  signs  afforded  by  inspection  and 
measurement,  by  palpation,  and  by  per- 
cussion and  auscultation,  which  are  of 
value  in  diagnosis.  The  results  of  this 
inquiry  may  be  arranged  in  the  following 
order : 

INSPECTION 

1.  Visible  enlargement  of  the  abdo- 
men is  more  often  general  in  cases  of 
ovarian  tumour,  and  partial  in  cases  of 
uterine  tumour,  being  confined  to  the 
lower  part  of  the  abdomen  until  a  very 
large  size  has  been  attained. 

2.  The  depression  of  the  umbilicus  is 
diminished,  or  the  umbilicus  may  become 
prominent  in  large  ovarian  cysts.  This  is 
rarely  seen  in  uterine  tumours  unless  fluid 
is  also  present  in  the  peritoneal  cavity. 


3.  Enlargement  of  the  superficial  veins 
of  the  abdominal  wall,  and  oedema  of  the 
abdominal  wall  and  of  the  linea2  albicantes, 
are  more  general  in  uterine  than  in  ovarian 
tumours  of  moderate  size,  but  are  not 
uncommon  when  ovarian  tumours  have 
attained  a  very  large  size. 

4.  "When  the  abdominal  wall  is  thin, 
both  uterine  and  ovarian  tumours,  if  not 
very  closely  adherent  to  the  abdominal 
wall,  may  be  seen  to  move  downwards  as 
a  recumbent  patient  inspires,  and  upwards 
during  expiration,  falling  downwards  and 
forwards  as  she  sits  or  stands,  and  more  or 
less  to  either  side  according  to  the  inclina- 
tion of  her  body.  But  nearly  all  uterine 
tumours,  though  visibly  moving  above, 
seem  to  be  fixed  below  in  the  hypogastric 
region. 

5.  "When  a  recumbent  patient  attempts 
to  sit  up  without  aid  from  any  other  than 
the  abdominal  muscles,  the  recti  are  seen 
to  bulge  forward  in  fi'ont  of  a  tense  non- 
adherent ovarian  tumour  or  with  a  flaccid 
adherent  cyst.  This  is  seldom  well  marked 
in  uterine  tumours,  a  solid  mass  fixed 
centrally  below  the  umbilicus  interfering 
with  the  free  action  of  the  recti. 

MEASUREMENT 

6.  Increase  in  the  circular  measure- 
ment of  the  abdomen  is  usually  greater 
on  one  side  than  the  other  in  ovarian 
tumours.  In  uterine  tumours  the  increase 
is  more  often  symmetrical.  In  both  classes, 
vertical  measurement  shows  the  distance 
between  the  pubes  and  the  sternum  to  be 
increased.  But  very  great  proportionate 
increase  of  the  space  irom  the  pubes  to 
the  umbilicus  is  more  common  in  uterine 
than  in  ovarian  tumours. 

PALPATION 

7.  Large  masses  of  apparently  solid 
matter,  and  smaller  masses  or  nodules  of 
very  hard  or  bonelike  substance,  are 
sometimes  observed  in  ovarian  tumours. 
But  it  is  excessively  rare  to  find  such 
solid  T^oxiion^  preponderating  in  an  ovarian 
tumour.  As  a  rule,  the  fluid  or  cystic 
portion  is  the  larger,  the  hard  or  solid 
portion  the  smaller,  in  ovarian  tumours. 
In  uterine  tumours,  on  the  contrary,  the 
solid  is  the  larger,  the  fluid  the  smaller 
portion. 

8.  The  mobility  of  ovarian  tumours 
is  generally  greater  from  below  upwards 


UTERINE  TUMOUKS 


139 


than  that  of  uterine  tumours,  unless  the 
latter  are  distinctly  pedunculated.  If  one 
hand  be  pressed  backwards  between  the 
tumour  and  the  pubes,  an  ovarian  tumour 
can  generally  be  raised  considerably,  and 
the  hand  can  sometimes  be  pressed  back- 
wards almost  to  the  brim  of  the  pelvis ; 
while  a  tumour  which  involves  the  body 
and  neck  of  the  uterus  cannot  be  raised 
at  all,  or  only  with  difficulty,  and  the 
hand  cannot  be  pressed  down  between  the 
pubes  and  the  tumour. 

9.  When  there  is  fluid  free  in  the 
peritoneal  cavity,  and  a  hard  tumour  can 
be  felt  on  displacing  this  fluid  by  sudden 
pressure,  the  tumour  may  be  either 
uterine  or  ovarian.  If  the  tumour  be 
very  hard  and  the  quantity  of  fluid  small, 
the  tumour  is  probably  uterine  and  the 
fluid  ascitic.  An  ovarian  tumour  which 
has  given  way,  and  emptied  one  or  more 
of  its  cysts  into  the  peritoneal  cavity,  is 
seldom  hard  or  well  defined  in  outline, 
and  the  quantity  of  fluid  is  often  so  large 
that  the  size  and  shape  of  the  tumour 
cannot  be  ascertained  until  after  removal 
of  the  fluid  by  tapping.  The  characters 
of  the  fluid  will  then  complete  the 
diagnosis. 

PERCUSSION 

10.  As  percussion  elicits  a  dull  sound 
all  over  both  uterine  and  ovarian  tumours, 
which  dulness  ceases  abruptly  at  the 
border  or  outline  of  the  tumour  in  all 
positions  of  the  patient — except  in  the 
rare  cases  Avhere  a  cyst  contains  gas,  or 
where  a  coil  of  intestine  is  adherent  in 
front  of  a  tumour — percussion  cannot 
affbrd  much  aid  in  distinguishing  ovarian 
from  uterine  tumours. 


AUSCULTATION 

11.  In  ovarian  tumours  the  impulse 
from  the  aorta  is  often  perceptible,  and  a 
sound  sometimes  accompanies  the  impulse. 
The  sounds  of  the  heart  are  rarely  trans- 
mitted, and  any  distinct  vascular  murmur 
is  excessively  rare.  But  in  about  half  the 
cases  of  uterine  tumours  which  I  have 
examined  some  variety  of  vascular  murmur 
may  be  heard.  In  some  cases  the  murmur 
is  tubular,  in  others  vesicular,  and  some- 
times a  tubular  and  a  vesicular  murmur 
may  be  heard  in  different  parts  of  a 
uterine  tumour.  These  murmurs  are 
synchronous  with  the  pulse.     They  may 


vary  in  intensity  with  the  amount  ot 
pressure  by  the  stethoscope,  and  may  dis- 
appear on  very  firm  pressure.  Common 
in  uterine,  very  rare  in  ovarian  tumours, 
vascular  murmurs  are  valuable  aids  in 
diagnosis. 

EXAMINATION   BY    VAGINA    AND    RECTUM 

Having  thoroughly  examined  the  abdo- 
men, the  pelvis  is  next  to  be  examined  by 
the  vagina  and  rectum,  and  a  conjoined 
examination  of  the  tumour  by  the  abdo- 
men and  pelvis  should  also  be  made. 

Examination  of  the  vagina  may  at 
once  remove  all  doubt,  by  showing  that 
the  OS  and  cervix  uteri  are  in  a  healthy 
state,  that  the  uterus  is  normally  mobile, 
that  its  cavity  is  neither  elongated  nor 
shortened,  and  that  any  tumour  felt 
through  the  vaginal  wall  is  independent 
of  the  uterus.  In  such  a  case  the  tumour 
is  almost  certainly  ovarian.  On  the  con- 
trary, we  may  find  the  vagina  more  or 
less  completely  obliterated  by  a  solid 
mass,  the  cervix  uteri  gone,  the  os  reached 
with  difficulty,  the  cervical  canal  so  closed 
or  distorted  that  the  u  erine  sound  cannot 
be  passed,  or  the  cavity  may  be  so  en- 
larged or  elongated  that  the  sound  may 
pass  many  inches  beyond  the  normal 
length.  Here  the  tumour  is  almost  cer- 
tainly uterine.  The  sound  may  also  give 
valuable  information  as  to  the  extent  oi 
the  connection  of  the  ingrowth  with  the 
wall  of  the  cavity. 

But  it  must  be  remembered  that 
considerable  peritoneal  outgrowths,  or 
large  growths  within  the  walls  of  the 
fundus  or  body  of  the  uterus,  have  been 
observed,  while  the  uterine  cavity  has  re- 
mained unaltered  in  dimensions  and  the 
cervix  in  structure.  And,  on  the  other 
hand,  the  cervix  may  be  draAvn  up  out  of 
reach,  or  the  whole  uterus  may  be  elon- 
gated, when  the  connection  with  an 
ovarian  tumour  is  close;  or  the  lower 
portion  of  an  ovarian  tumour  may  be  so 
moulded  to  the  true  pelvis  that  the  uterus 
is  pressed  upwards  and  forwards,  or  flat- 
tened behind  the  pubes,  so  that  the 
tumour  and  the  uterus  are  either  really 
or  apparently  inseparable  from  one  an- 
other. Abnormal  arterial  impulse  in  the 
vagina  and  cervix  uteri  may  be  felt  in 
both  classes  of  tumours.  In  one  case  I 
found  during  the  operation  that  the 
pulsations  at  the  base  of  a  uterine  tumour 
arose  from  some  large  vessels  in  a  portion 


i4t) 


UTEEINE   AND   OTHEE   ABDOMINAL   TUMOUES 


of  omentum  which  had  contracted  adhe- 
sions low  down.  The  pulsating  omental 
vessels  had  been  felt  through  the  vagina. 
But  T  have  never  felt  the  vascular  thrill 
Jike  that  of  varicose  aneurism,  occasionally 
felt  in  the  lower  segment  of  a  fibroid 
uterus,  in  any  ovarian  tumour.  I  have 
felt  this  thrill  in  some  20  to  30  cases,  and 
thought  it  of  some  value  in  the  differential 
diagnosis  between  uterine  and  ovarian  tu- 
mours, but  I  never  suggested  that  the 
thrill  was  due  to  the  presence  of  an 
aneurism.  Yet  Dr,  Bailey,  of  Louisville, 
Kentucky,  furnished  me  with  a  curious 
•exemplification  of  the  ease  with  which 
■even  intelligent  commentators  may  put 
different  interpretations  upon  the  simplest 
bit  of  text  when  they  overlook  the  context. 
In  consultation  with  other  eminent  prac- 
titioners, he  saw  a  patient  who  for  8 
or  10  years  had  had  fibroid  tumours  of 
the  uterus,  and  he  wrote  to  me  thus  : 
^  Latterly  a  new  feature  occurred  in  the 
case.  AH  the  phenomena  of  an  aneurism 
appeared  in  the  lower  segment  of  the 
uterus.  A  purring  thrill  could  be  heard 
•and  felt  very  distinctly  indeed.  Several 
very  prominent  gynaecologists  unhesita- 
tingly pronounced  it  aneurism.  Upon 
the  paragraph  quoted  from  your  work  I 
stated  that  you  taught  that  the  phenomena 
of  varicose  aneurism  occurred  in  the  lower 
segments  of  fibroid  uteri  witnout  there 
being  aneurism.  Did  I  interpret  your 
language  correctly  ?  Dr.  Atlee,  of  Phil- 
adelphia, as  well  as  the  other  eminent 
gentlemen,  maintained  that  you  merely 
expressed  the  idea  that  fibroid  uteri  had  a 
pulsatory  thrill  in  their  lower  segments 
that  was  not  found  when  the  tumours 
were  ovarian.  Noav  while  this  is  true,  I 
claimed  that  your  language  taught  more 
than  this — namely,  that  the  lower  segments 
of  fibroid  uteri  occasionally  gave  out  all 
the  phenomena  of  varicose  aneurism  when 
there  was  no  aneurism,  and  that  this  was 
not  the  case  with  ovarian  tumours. 

'  Dr.  Atlee  performed  gastrotomy,  and 
as  the  shock  and  loss  of  blood  lost  to  him 
the  patient  upon  the  table,  the  dissection 
of  the  tissues  where  the  aneurismal  phe- 
nomena had  presented  themselves  de- 
monstrated no  aneurism.  So  if  I  have 
interpreted  your  teachings  aright  they 
have  in  this  case  received  additional 
support.' 

In  order  to  prevent  any  further  mis- 
reading of  my  words,  in  which,  however, 
I  can  see  nothing  equivocal  when  taken 


in  their  connection,  I  may  notify  that  I 
fully  accept  Dr.  Bailey's  construction,  and 
gladly  add  his  case  as  an  illustration  of 
the  truth  of  what  I  wrote. 

The  vaginal  walls  may  be  so  de- 
pressed, when  there  is  much  fluid  free  in 
the  peritoneal  cavity  surrounding  either  a 
uterine  or  an  ovarian  tumour,  as  to  form 
a  vaginal  rectocele,  more  rarely  a  vaginal 
cystocele.  And  the  uterus  may  either 
remain  above  the  brim  of  the  pelvis  if 
greatly  enlarged,  or  if  fixed  by  adhesion ; 
or  it  may  prolapse  with  the  vagina,  the 
OS  appearing  at  the  most  depending  part 
of  the  protrusion.  Here  the  uterine 
sound  will  generally  remove  all  doubt ; 
for  if  the  dimensions  of  the  uterine  cavity 
are  normal,  and  the  weight  of  the  uterus 
is  not  increased,  the  tumour  can  hardly  be 
uterine.  And  a  uterus  which  is  not  much 
enlarged  can  generally  be  pushed  up  to 
its  normal  position. 

In  some  cases  where  the  uterus  is 
much  elevated,  it  may  be  felt  through  the 
abdominal  wall  above  the  pubes,  while 
the  OS  uteri  cannot  be  reached  by  the 
vagina.  The  urethra  may  be  elongated 
or  drawn  to  one  side,  and  the  bladder 
may  also  be  displaced.  If  the  abdominal 
tumour  and  the  pelvic  portion  of  the 
tumour  fluctuate,  while  the  uterus  does 
not  much  exceed  its  normal  dimensions, 
it  is  almost  certain  that  the  uterus  is 
adherent  to,  and  is  elevated  by,  an 
ovarian  tumour. 

Examination  by  the  rectum  may 
show  that  the  uterus  preserves  its  normal 
size,  shape,  and  position.  Or  it  may  be 
displaced  by  some  tumour  above  or  in 
front  ol  it,  and  one  or  both  ovaries  may 
sometimes  be  felt.  This,  however,  is  nut 
very  common  if  they  are  not  enlarged  nor 
lower  in  the  pelvis  than  usual.  By  one 
finger  in  the  rectum  and  another  in  the 
vagina,  the  consistence,  form,  and  size  of 
any  intervening  structure  can  be  ascer- 
tained and  valuable  information  so  ob- 
tained. And  if  the  sound  be  passed  into 
the  uterine  cavity,  and  examination  then 
made  by  the  rectum,  it  is  often  easy  to 
ascertain  whether  any  solid  or  fluid  tu- 
mour is  situated  between  a  normal  uterus 
and  the  rectum,  or  whether  the  uterus  is 
fixed  and  its  posterior  part  enlarged. 

When  a  tumour  can  be  felt  in  the 
pelvis  by  vagina  and  rectum,  as  well  aa 
in  the  abdomen  by  the  abdominal  wall, 
simultaneous  examination  will  be  required 
to   ascertain   if  there  is  more  than   one 


UTERINE  TUMOURS 


141 


tumour,  and  if  the  uterus  is  independent 
or  not.  Pressing  one  finger  firmly  on  the 
cervix  uteri,  and  moving  the  abdominal 
tumour  with  the  other  liand  from  side  to 
side,  then  upwards  and  do;v'n\vards,  the 
uterus  may  be  felt  to  remain  almott  un- 
affected by  the  movements  of  the  tumour, 
or  only  to  receive  some  transmitted  move- 
ment as  the  pelvic  portion  of  the  tumour 
moves.  Here  the  strong  probability  is 
that  the  tumour  is  ovarian.  On  the  other 
hand,  every  movement  of  the  abdominal 
tumour  may  be  communicated  imme- 
diately to  the  uterus,  Avhich  is  felt  to 
move  in  all  directions  with  the  pelvic 
portion  of  the  tumour.  If  this  portion  is 
solid,  it  is  almost  certain  that  the  tumour 
is  uterine. 

Cases  are  sometimes  met  with  where 
ovarian  tumours  and  fibroid  tumours  of 
the  uterus  are  both  present  at  the  same 
time.  Small  uterine  fibroids  are  often 
observed  when  the  only  important  tumour 
is  ovarian.  I  have  seen  a  large  cyst  of 
one  ovary  and  a  large  uterine  fibroid  co- 
existing. I  have  twice  seen  tumours  of 
both  ovaries  present  when  the  uterus  was 
enlarged  by  fibroids,  and  several  cases 
where  both  uterus  and  ovaries  were  sim- 
ultaneously affected  by  malignant  disease. 
In  (Jase  979,1  removed  an  ovarian  tumour 
weighing  7  pounds,  and  a  fibroid  out- 
growth from  the  uterus  weighing  2 
pounds.  And  in  1882  I  removed  a  der- 
moid tumour  of  the  left  ovary,  and  a 
fibroid  outgrowth  from  the  right  side  of 
the  uterus.  Both  these  patients  were 
young  unmarried  women,  and  both  re- 
covered. 

EXPLORATORY    INCISION 

If  these  possible  complications  be 
borne  in  mind,  such  an  examination  as  I 
have  suggested  will  in  most  cases  suffice 
to  establish  an  accurate  diagnosis  between 
uterine  and  ovarian  tumours.  In  some 
cases  doubt  may  still  remain,  and  ex- 
ploratory puncture  or  incision  will  then 
be  necessary.  When  a  uterine  outgrowth 
is  not  entirely  solid — but  partly  solid  and 
partly  fluid  or  cystic — forming  a  fibro- 
cystic tumour — the  diagnosis  is  still  more 
difficult.  A  case  of  fibro-cystic  tumour 
of  the  uterus  was  reported  by  me  in  the 
'  Dublin  Quarterly  Journal  of  Medical 
Science,'  Aug.  1864.  The  report  has 
been  reprinted  in  each  of  my  works  on 
diseases  of  the  ovaries.     Although  prac- 


tically important,  and  historically  in- 
teresting, as  a  sort  of  landmark  indicating 
one  stage  in  the  settling  of  the  principles 
of  our  diagnosis,  and  the  date  at  which  it 
became  generally  known  that  fibro-cystic 
tumours  of  the  uterus  could  contain  so 
large  a  quantity  of  fluid  as  to  bring  them 
into  diagnostic  comparison  Avith  ovarian 
cysts,  and  marking  the  limits  of  safety  in 
any  operative  proceedings  undertaken 
either  for  determining  the  nature  of  the- 
growth  or  the  possibility  of  its  removal, 
it  is  unnecessary  now  to  repeat  all  the 
details.  The  patient  was  a  single  lady,  45 
years  of  age,  with  the  abdomen  enor- 
mously distended,  measuring  5G  inches  iri 
girth  at  the  level  of  the  umbilicus,  19 
inches  from  the  ensiform  cartilage  to  the 
umbilicus.  The  skin  covering  the  um- 
bilicus was  distended  by  fluid  simulating 
an  umbilical  hernia.  Above  the  um- 
bilicus fluctuation  was  very  evident;  but 
the  fluid  was  evidently  free  in  the  peri- 
toneal cavity,  and  covered  a  solid  or 
semi-solid  tumour  that  could  be  felt  on 
displacing  the  fluid  by  deep  pressure. 

I  first  tapped  above  the  umbilicus, 
and  removed  about  oO  pints  of  clear 
rather  viscid  fluid.  After  removing  the 
canula,  and  closing  the  small  opening, 
I  made  an  incision  below  the  umbilicus 
about  6  inches  long,  and  exposed  what 
appeared  to  be  2  ovarian  cysts  separated 
by  a  deep  fissure.  I  tapped  that  on  the 
left  side,  and  about  10  pints  of  bloody 
serum  escaped ;  2  or  3  pints  more  of 
similar  red  fluid  escaped  after  puncturing 
again  within  the  cyst  first  opened,  by 
pushing  on  the  trocar  without  removing 
the  canula.  The  tumour  was  then  with- 
drawn, and  found  to  have  .2  attachments 
— one  above  to  the  tumour  on  the  right 
side,  and  one  below  to  the  uterus.  The 
former  attachmi^nt  was  broken  through, 
and  2  bleeding  vessels  on  the  torn  surface 
of  the  right  tumour  were  secured  by  silk 
ligatures.  The  left  broad  ligament  was 
then  transfixed,  tied  in  two  halves  with 
strong  silk,  and  the  tumour  was  cut  away. 
It  then  became  a  question  what  should 
be  done  with  the  tumour  on  the  right 
side ;  and,  looking  to  its  great  size, 
solidity,  evident  close  connection  with  the 
transverse  colon  and  with  the  omentum, 
which  contained  some  enormously  dis- 
tended veins,  it  was  decided  that  no 
attempt  to  remove  this  tumour  should  be 
made,  especially  as  the  patient  was  be- 
coming   very   feeble.     The    wound    was 


142 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


accordingly  closed  and  the  patient  placed 
in  bed.  Brandy  was  administered  freely  ; 
but  she  never  rallied  nor  recovered  con- 
sciousness, and  died  about  3  hours  after 
she  had  begun  to  take  chloroform. 

The  tumour  which  I  removed  weighed 
about  20  pounds,  and  was  almost  entirely 
solid.  It  consisted  of  fibrous  tissue, 
everywhere  permeated  by  large  blood- 
ve^^sels,  and  in  several  places  there  were 
blood  cysts,  the  size  of  a  barley-corn  to 
that  of  a  pea.  The  largest  cyst  was  at 
the  superior  extremity  ;  it  was  about  the 
size  of  an  adult  head,  and  its  internal  sur- 
face presented  traces  of  having  primarily 
been  divided  into  several  compartments. 

The  tumour  which  we  did  not  attempt 
to  remove  was  found  after  death  to  con- 
sist partly  of  a  cyst  and  partly  of  a  fibro- 
cystic tumour.  The  cyst  was  spherical, 
about  a  foot  in  diameter,  empty,  and  it 
adhered  to  the  anterior  abdominal  wall 
and  to  the  transverse  colon ;  the  fibroid 
mass  measured  18  inches  in  length,  16 
inches  in  breadth,  and  near  its  centre 
fully  7  inches  thick. 

The  walls  of  the  uterus  were  of  nor- 
mal thickness.  From  the  fundus  sprang 
a  fibrous  column,  5  inches  long,  3  inches 
deep,  and  1^  inch  broad,  encircled 
at  its  upper  extremity  by  a  ligature. 
The  left  side  of  this  fibrous  column  pre- 
sented a  roughly  cut  surface,  5  inches 
long  and  3  inches  broad  or  deep,  being 
the  point  at  which  the  tumour  first 
described  had  been  cut  through  at  the 
operation. 

In  the  14th  volume  of  the  '  Trans- 
actions of  the  Pathological  Society  of 
London,'  p.  204,  may  be  found  a  short 
account  of  a  fibro-cystic  tumour  of  the 
uterus  which  I  removed  from  a  single 
lady,  aged  53,  on  April  30,  18C3. 
'  One  large  cyst  had  held  26  pints  of 
fluid  and  4  pounds  of  fibrine  ;  and  there 
was  a  solid  mass,  which  weighed  more 
than  16  pounds.  It  was  not  imtil  after 
post-mortem  examination  that  the  true 
nature  of  the  case  was  discovered. 
Given  a  large  semi-solid  tumour,  fluctu- 
ating in  some  parts,  containing  cysts 
holding  upwards  of  20  pints  of  fluid, 
moving  beneath  the  abdominal  wall,  the 
uterus  being  movable,  and  not  enlarged 
so  far  as  measurement  by  the  sound  can 
detect,  no  sound  or  arterial  impulse  to  be 
heard  which  is  not  often  heard  in  ovarian 
tumours,  and  no  history  of  haemorrhage 
leading  to  a  suspicion   of  uterine  disease 


— and  it  will  be  admitted  that  these 
characters  of  the  two  fibro-cystic  tumours 
of  the  uterus  which  I  removed  so 
closely  resemble  those  of  semi-solid 
ovarian  tumours,  that  diagnosis  must 
be  very  uncertain.  Even  after  an  ex- 
ploratory incision,  I  know  of  nothing 
but  a  rather  darker — less  pearly — aspect 
of  the  tumour  Avhich  would  put  the 
surgeon  on  his  guard.  In  any  doubtful 
case  it  Avould  be  well  to  tap  the  largest 
cyst  and  examine  the  fluid.  In  both  the 
above  cases,  as  in  others  since,  this  was 
peculiar — not  the  viscid  mucoid  fluid  of 
multilocular  ovarian  cysts,  but  a  thin 
serum,  with  5,  10,  or  15  per  cent,  of 
blood  intimately  mixed  with  it,  and  not 
separating  until  after  standing  for  some 
hours.  In  this  way  I  have  satisfied 
myself,  in  several  cases,  that  tumours, 
which  others  considered  to  be  ovarian, 
were  really  fibro-cystic  uterine  growths. 
If  the  operation  has  been  commenced,  and 
the  dark  aspect  of  the  tumour  is  observed, 
it  would  certainly  be  advisable  not  to  do 
more  than  tap  one  or  more  of  the  largest 
cysts  before  examining  attentively  the 
connections  between  the  uterus  and  the 
tumour.  If  these  should  prove  to  be 
very  intimate,  it  will  be  the  iinpleasant 
duty  of  the  surgeon  to  desist  from  any 
attempt  to  do  more,  and  to  close  the 
wound  as  soon  as  possible.'  We  shall  see 
presently  how  recent  experience  modifies 
this  last  sentence. 

MEDICAL    TREATMENT 

There  is  more  time  for  the  treatment 
with  patients  suffering  from  fibroid  tu- 
mours of  the  uterus  of  moderate  size  than 
with  those  who  are  subject  to  the  more 
rapid  course  of  ovarian  cysts.  Even  when 
the  symptoms  are  urgent  we  have  time  to 
try  a  variety  of  medical  resources,  not  only 
for  the  relief  of  symptoms,  but  with  some 
hope  of  arresting  growth  before  resorting 
to  surgical  measures  ft)r  extirpation. 
When  the  tumour  has  attained  a  consider- 
able size,  one  of  the  first  things  which 
strikes  us  is  the  distress  arising  from  the 
pendulous  state  of  the  abdomen.  We 
net  rid  of  this  trouble  at  once  by  a  suit- 
able bandage  or  apparatus,  and  put  the 
patient  at  comparative  ease.  The  support, 
too,  may  be  carried  to  an  extent  sufficient 
to  steady  the  tumour,  and  to  prevent  the 
pain  caused  by  its  rolling,  and  falling 
upon  the   sensitive  viscera  with  which  it 


UTERINE  TUMOURS 


143 


comes  in  contact  as  the  patient  moves 
about.  But  beyond  this  pro\tection  pres- 
sure is  useless,  and  it  is  generally  in  vain 
that  it  is  employed  to  get  any  amount  of 
absorption  ;  to  say  nothing  of  the  aggra- 
vation of  other  symptoms  by  any  great 
degree  of  constriction.  Without  this 
girding,  the  weight  of  the  tumour  pressing 
upon  nerves,  vessels,  and  the  abdominal 
organs  is  enough  to  cause  distress,  for 
which  we  have  to  find  means  of  relief. 
We  sometimes  meet  with  the  most  excru- 
ciating sciatica  when  the  tumour  sinks 
down  in  the  pelvis,  and  the  pain  can  only 
be  moderated  by  changes  of  position,  and 
dislodging  the  mass  from  the  place  where 
it  has  become  impacted.  Without  such 
manual  interference  embrocations  and  sub- 
cutaneous injections  are  thrown  away. 
We  must  deal  in  the  same  way  with 
any  other  part  which  is  the  seat  of  neu- 
ralgia from  the  same  cause.  At  the  same 
time,  we  are  doing  as  much  as  possible 
to  remove  the  vascular  obstruction  Avhich 
is  giving  rise  to  congestion  and  oedema, 
though  it  will  often  be  found  that  bandages 
on  the  lower  limbs,  when  they  are  much 
swollen,  are  an  additional  means  of  com- 
fort to  the  patient.  With  the  presence  of 
a  foreign  body,  such  as  one  of  the  fibroid 
tumours,  encroaching  upon  the  space  duly 
adjusted  for  the  joint  occupation  and  action 
of  the  several  abdominal  viscera,  some  or 
all  of  them  must  needs  be  interfered  with 
and  their  functions  embarrassed.  Thus 
we  see  produced  all  the  evils  of  lymphatic 
engorgement,  of  impeded  intestinal  action, 
of  renal  and  vesical  irregularity.  We  may 
have  to  exert  all  our  ingenuity  to  disengage 
the  lymph  channels,  to  assist  imperfect  di- 
gestion, disperse  flatulence,  moderate  spas- 
modic pains,  overcome  constipation,  and 
take  off  tenesmus — all  which  things,  to- 
gether or  alternately,  make  life  a  torment. 
Pancreatic  and  hepatic  difficulties  are 
often  very  marked,  and  need  to  be  at- 
tended to.  The  bladder  symptoms  some- 
times become  distressing,  and  pressure 
in  the  ureters  may  suspend  kidney  func- 
tion and  give  rise  to  the  well-known 
symptoms.  Beyond  these  troubles  of  the 
mechanism  of  organic  life,  we  may  find 
the  vital  organs  of  the  thorax  no  less 
affected,  and  when  we  come  to  add  the 
host  of  miseries  from  diverse  reflex  action, 
there  is  an  ample  field  for  the  art  of 
relieving  medicine  to  show  its  powers. 
Then  the  Avhole  range  of  constitutional 
effects  have  to  be  considered,  and  every- 


thing compatible  with  the  circumstances 
and  condition  of  the  patient  must  be  done 
to  maintain  the  general  health,  since  the 
better  the  condition  of  the  patient  the 
less  rapid  will  be  the  development  of  the 
embryonic  tissues  forming  the  tumour. 
Change,  moral  support,  sedatives,  tonics, 
nourishment,  must  all  be  regulated 
according  to  circumstances.  The  loss  of 
blood,  generally  aggravated  periodically, 
is  one  of  the  most  serious  consequences 
of  fibroid  tumours,  especially  of  those  in- 
growing ot  seated  in  the  walls  of  the 
viterus.  This  has  to  be  restrained.  The 
most  important  matter  here  is  rest,  and 
this  ought  to  be  absolute.  Some  sur- 
geons trust  very  much  to  dilatation  of  the 
cervical  canal,  or  to  the  effect  of  incisions, 
followed  by  the  application  of  styptics. 
Of  these  there  are  many ;  none,  perhaps, 
better  than  the  preparations  of  iron. 
Sometimes  it  may  become  necessary  to 
plug  the  vagina  or  to  use  injections.  At 
the  same  time,  internal  remedies  of  the 
same  character  can  be  given  with  advan- 
tage. Most  men  have,  after  a  time,  their 
preferences,  and  familiarity  with  the  use 
of  certain  agents  often  gives  unexpected 
power  in  the  use  of  them.  I  have  fre- 
quently tested  the  long-continued  employ- 
ment of  the  perchloride  of  mercury  with 
bark,  and  I  believe  the  good  results  from 
it  are  mainly  due  to  its  action  on  the 
digestive  organs,  and  to  its  effect  in 
restoring  and  keeping  up  the  general 
health.  It  conduces,  too,  as  much  as  any- 
thing, to  what  we  may  hope  to  do  in  the 
way  of  cure — that  is  to  say,  in  checking 
the  growth,  or  promoting  the  absorption, 
of  the  tumour.  With  this  end  in  view,  I 
have  also  given  chloride  of  ammonium, 
alone  or  with  the  bromide,  for  a  long 
time,  and  in  many  cases  with  apparent 
benefit.  A  great  variety  of  absorbent 
remedies  have  been  suggested,  but  from 
none  of  them  can  any  good  be  expected. 
The  subcutaneous  injection  of  ergotine  or 
of  sclerotic  acid  is  said  to  have  brought 
about  a  diminution  of  size,  while  at  the 
same  time  it  controlled  the  haemorrhage, 
and,  b}'  giving  the  patient  comfort,  en- 
abled her  to  gain  health  and  strength. 
Ergot,  in  the  form  of  liquid  extract, 
given  internally,  acts  in  the  same  way. 
Wonderful  reports  have  also  been  made 
of  the  effect  of  the  Kreuznach  and  Wood- 
hall  Spa  waters,  and  even  of  the  home 
use  of  the  salts  obtained  from  them,  and 
one  may  suppose  that  there  is  some  truth 


144 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


therein,  or  the  popularity  of  the  springs 
would  not  have  outlasted  the  common 
duration  of  credulity.  At  one  time  the 
artificial  petrifaction  of  the  tumour  by 
the  continued  administration  of  chloride 
of  calcium,  in  imitation  of  the  natural 
process  of  calcification  which  occasionally 
takes  place,  seemed  to  promise  a  chance  of 
success,  at  least  in  arresting  the  growth 
of  fibroid  tumours;  but  the  equal  affinity 
of  the  arterial  coats  for  this  substance 
brought  patients  into  a  serious  dilemma, 
and  it  seemed  better  for  them  to  go  on 
strugpling  for  life  with  a  non-malignant 
parasite,  than  to  run  any  risk  of  losing  it 
by  the  failure  of  a  damaged  circulating 
apparatus. 

Tumours  not  projecting  into  the 
cavity  of  the  uterus  are  no  bar  to  mar- 
riage. A  pregnancy  may  even  give  the 
chance  of  getting  rid  of  the  tumour  by  an 
involution  coincident  with  that  of  the 
uterus  after  delivery. 

SURGICAL    TREATMENT 

This  may  be  most  conveniently  dis- 
cussed in  detail  according  to  the  varieties 
of  the  tumours  to  be  operated  on  in  the 
following  order:  1st,  fibroid  or  fibro- 
cystic sub-peritoneal  outgrowths ;  2nd, 
mural  or  interstitial  growths ;  3rd,  in- 
growths. The  alternative  practice  of 
removing  the  ovaries  instead  of  the 
uterine  tumour  will  afterwards  be  con- 
sidered. 

INDICATIONS    FOR    MYOMOTOMY 

Before  considering  the  methods  of 
operating  in  these  three  classes  of  cases, 
the  surgeon  has  to  decide  whether  any 
operation  should  be  recommended,  or 
whether  the  patient  should  be  advised  to 
wait  either  imtil  some  clear  necessity  for 
relief  removes  all  doubt,  or  until  the 
ordinary  changes  in  the  uterus  which  fol- 
low the  cessation  of  the  catamenia  are 
accompanied  or  followed  by  diminution 
in  the  morbid  growth  and  by  the  dis- 
appearance of  the  distressing  symptoms 
depending  upon  it.  Here  ovariotomy  and 
myomotomy  stand  upon  very  different 
grounds.  I  adopt  the  word  'myomotomy' 
because,  without  being  etymologically 
accurate,  it  is  becoming  pretty  generally 
received  as  a  convenient  term  for  the 
removal  of  uterine  tumours.  With  some 
rare  exceptions,  ovarian  tumours,  if  not 


removed,  kill  the  patient  within  4  years. 
Innocent  uterine  tumours,  on  the  con- 
trary, may  persist  for  many  years  almost 
without  the  knowledge  of  the  patient, 
are  often  discovered  quite  accidentally, 
and  as  age  advances  disappear  more  or 
less  completely,  without  shortening  life 
or  leading  to  any  important  affection  of 
the  general  health.  It  is  only  when 
accompanied  by  free  bleeding  or  by  the 
formation  of  ascitic  fiuid  that  uterine 
tumours  of  moderate  size,  and  not  rapidly 
increasing,  should  be  operated  upon  in 
any  way ;  or  when  pressure  on  intestine, 
bladder,  uterus,  or  nerves  causes  symptoms 
which  can  only  be  relieved  by  removal  of 
the  tumour ;  or  the  case  is  complicated 
by  pregnancy.  When  a  uterine  tumour 
attains  a  very  large  size,  the  suffering 
caused  by  its  Aveight  and  pressure,  and  by 
its  interference  with  the  respiration,  is 
sufficient  to  justify  operation  at  even  great 
risk.  Putting  aside  cases  where  the  great 
size  of  the  tumour  is  the  only  indication 
for  operation,  the  other  indications  for  the 
removal  of  tumours  of  moderate  size  are. 
either  their  rapid  increase,  some  inflam- 
matory or  other  changes  in  the  tumour 
causing  fever,  profuse  bleeding,  peritoneal 
irritation  with  ascitic  effusion,  or  local 
consequences  depending  directly  upon 
pressure.  At  the  present  day,  the  indi- 
cations for  the  operation  have  to  be  con- 
sidered under  very  different  estimates  as 
to  the  probable  results  of  its  performance 
than  could  have  been  calculated  upon  20 
years  ago.  Up  till  about  the  year  1865, 
when  ovariotomy  was  beginning  to  be 
accepted  as  a  legitimate  surgical  opera- 
tion, uterine  tumours  Avere  scarcely  ever 
removed  designedly.  The  rule  was,  that 
when  a  surgeon,  performing  Avhat  he 
expected  to  be  ovariotomy,  found  that  he 
had  made  a  mistaken  diagnosis,  and  Avas 
unexpectedly  called  upon  to  deal  Avith  a 
uterine  tumour,  he  should  desist.  In 
many  cases  he  desisted.  The  Avound  was 
closed.  But  in  some  exceptional  cases 
tumours  Avere  removed,  and  as  the  num- 
bers of  such  cases  increased,  technical  de- 
tails in  the  mode  of  operating  Avere  learnt. 
Kimball's  operation  in  September  1853 
appears  to  be  the  first  in  Avhich  any  sur- 
geon, having  made  an  accurate  diagnosis, 
undertook  to  remove  the  tumour  Avith  a 
distinct  knoAvledge  of  Avhat  he  had  to  do. 
His  operation  Avas  followed  by  the  re- 
covery of  the  ])atient.  The  work  of  Pean 
and  Urdy,ou  '  Ilysterotomie,'  published  in 


UTERINE  TUMOURS 


14; 


1873,  probably  contains  the  first  systematic 
account  of  the  mode  of  removing  fibroid 
and  fibro-cystic  uterine  tumours.  The 
history  of  this  operation  is  by  them 
divided  into  3  very  distinct  periods. 
In  the  first,  before  1843,  surgeons,  meeting 
in  the  abdomen  with  uterine  tumours 
instead  of  the  ovarian  tumours  they 
expected,  shranlc  from  the  consequences 
of  proceeding,  and  did  not  complete  the 
operation  they  had  begun.  In  the  second 
period,  from  1843  to  18G3,  which  Pean 
calls  the  stage  of  essaying  and  groping-  — 
'  periode  d'essais  et  de  tatonnements' — 
and  when  ovariotomy  had  found  nume- 
rous followers,  some  surgeons,  finding 
themselves  after  an  error  of  diagnosis  in 
the  presence  of  a  uterine  tiimour,  impro- 
vised tlie  operation,  although  everything 
had  been  prepared  for  an  ordinary  ovario- 
tomy. This  is  true  only  to  a  certain 
extent,  for  in  Sept.  1861,  in  a  case  where 
before  operation  I  had  been  doubtful  as 
to  diagnosis,  and  went  prepared  either  to 
perform  ovariotomy,  or  to  deal  with  the 
suspected  contingency  of  a  uterine  fibroid, 
I  removed  a  solid  uterine  tumour  weigh- 
ing 27  pounds,  with  both  Fallopian  tubes 
and  both  ovaries;  and  in  January  1863 
I  enucleated  a  solid  tumour  weighing  16 
pounds,  previously  known  to  be  a  fibroid 
outgrowth  from  the  uterus,  after  a  very 
accurate  diagnosis  had  been  made  in  a 
careful  consultation  and  with  a  full  expla- 
nation of  the  unknown  risk  to  the  patient. 
In  another  case,  in  1863,  I  took  away  a 
fibro-cystic  tumour  weighing  46  pounds. 
The  third  period  dates  from  April  1863, 
Avhen  Kceberle,  in  a  case  of  doubtful 
diagnosis,  prepared  himself  for  either  con- 
tingency, and  decided,  before  he  began  the 
operation,  to  remove  the  whole  of  the  tu- 
mour, even  if  obliged  to  perform  a  supra, 
vaginal  amputation  of  the  uterus.  Inl866 
he  operated  3  times  in  cases  Avhere,  sure 
of  his  diagnosis,  he  designedly  performed 
hysterotomy  ;  and  it  is  claimed  for  the  dis- 
tinguished surgeon  of  Strasburg,  that  to 
him  the  honour  is  due  of  having  first 
performed  amputation  of  the  uterus  de- 
liberately, and  Avith  a  full  knowledge  of 
his  case.  The  latest  returns  of  Koeberle's 
practice  are  given  by  Bigelow  up  to  1882 
as  19  operations — 9  recoveries  and  10 
deaths.  Plan's  first  case  was  in  1869 — 
the  first  successful  case  in  Paris.  This 
was  a  fibro-cystic  tumour,  and  it  was  not 
until  1871  he  removed  a  solid  fibroid. 
Up  to  Feb.  1872,  Pean  had  operated  upon 


9  patients,  7  of  whom  recovered.  Before 
July  1881,  according  to  Bigelow,  Pean 
had  had  51  cases,  with  33  recoveries  and 
18  deaths. 

The  later  results  of  the  German  ope- 
rators, Hegar,  Kaltcnbach,  Schroeder  and 
Olshausen,  as  having  done  amongst  them 
the  greater  part  of  the  operations  in  their 
country,  enable  us  to  foim  some  com- 
parison between  the  results  of  myomo- 
tomy  when  the  treatment  of  the  pedicle, 
or  connection  with  the  utei'us,  is  extra  or 
intra-peritoneal,  and  Avhen  elastic  or  other 
ligatures  are  used.  In  the  latest  publica- 
tion which  I  have  seen,  that  of  Hofmeier, 
published  in  1884,  he  gives  the  results  of 
100  operations  by  Schroeder,  all,  with  one 
exception,  with  intra-peritoneal  treatment. 
Of  21  cases  where  the  tumours  were 
removed  without  opening  the  utei'ine 
cavity,  there  Avere  only  2  deaths;  of  58 
cases  where  the  uterine  cavity  Avas  opened 
there  Avere  18  deaths;  and  of  20  cases  of 
enucleation  of  the  uterine  tumours  there 
Avere  12  deaths;  making  in  all  100  cases, 
Avith  32  deaths.  Hofmeier  gives  the  re- 
sults of  Hegar  and  Kaltenbach's  opera- 
tions up  to  Sejot.  1881,  as  12  cases,  Avith 
only  1  death  ;  of  Kaltenbach's  only%  up  to 
1883,  as  10  cases,  Avith  only  1  death;  of 
Billroth's,  to  1882,  25  cases— 10  reco- 
veries and  15  deaths;  and  Olshausen's, 
to  1884,  29  cases — 20  recoveries  and  9 
deaths.  But  all  these  latter  numbers 
Avere  taken  from  Bigelow's  table  in  the 
'  American  Journal  of  Obstetrics,'  which 
table  certainly  requires  correction. 

Indeed,  the  Avhole  of  the  inquiry  as  to 
results  of  operation  upon  the  uterus  for 
fibroid  tumours  by  different  operators 
and  by  different  methods,  either  in 
Germany,  France,  Great  Britain  or 
America,  leads  to  the  conclusion  Avhich 
Schroeder,  in  his  preface  to  Ilofmeier's 
Avork,  has  expressed,  '  that  Avhile  ovaiio- 
tomy  may  now  be  looked  upon,  except  as 
regards  possible  advance  in  minute  de- 
tails, as  a  closed  chapter,  myomotomy, 
on  the  contrary,  stands  exactly^  in  the 
opposite  position.' 

I  perfectly  coincide  Avith  Avhat  Schroe- 
der says,  and  Avithout  venturing  to  lay 
down  any  distinct  rules  for  practice, 
Avill  proceed  to  illustrate  different  modes 
of  operating  by  narrating  part  of  Avhat 
I  have  done  myself.  The  Avhole  group 
shows  that  the  operation  is  more  suc- 
cessfully done  noAv  than  formerly,  and 
that,   Avhen   the  tumour  can  be  removed 

L 


146 


UTERIXE   AND   OTHER   ABDOMIXAL   TUMOURS 


withoixt  opening  the  uterine  cavity,  a 
better  hope  of  ri^covery  may  be  entertained 
than  when  the  cavity  must  be  cut 
through. 

THE    OPERATION'    OF    MYOMOTOMY 

For  every  patient  about  to  undergo 
the  operation  of  myomotomy,  the  same 
preparation  must  be  made,  and  the  same 
precautions  observed,  as  for  ovariotomy. 
The  patient  is  placed  on  the  table,  as  shown 
on  page  7G,  and  the  instruments  are  ar- 
ranged in  the  same  manner.  The  trocar 
is  only  necessary  when  the  tumour  is 
fibro-cystic.  The  instruments  required, 
not  usually  taken  to  an  ovariotomy,  are 
the  pins,  wire  constrictor,  or  a  large 
clamp,  to  be  ready  in  case  the  extra-peri- 
toneal method  is  selected,  iron  or  cojiper 
cauteries,  or  Paquelin's  cautery,  the 
cautery  clamp,  and  a  supply  of  elastic 
ligatures  of  different  sizes. 

Except  in  cases  of  small  solid  tumours, 
or  cases  in  which  considerable  cystlike 
cavities  may  be  emptied,  the  incision  Avill 
usually  be  much  longer  than  in  ovario- 
tomy ;  probably  extending  2  or  3  inches 
above  the  umbilicus,  possibly  quite  up  to 
the  ensiform  cartilage.  Even  more  caution 
than  in  ovariotomy  is  necessary  at  the 
lower  angle  of  the  incision,  as  the  bladder 
is  very  apt  to  be  pushed  or  drawn  up 
towards  the  umbilicus.  I  have  never  fol- 
lowed the  practice  of  Pean  in  what  he  calls 
'  morcellement,'  or  dividing  the  tumours 
into  several  parts  before  extraction,  in 
order  to  render  a  long  incision  unnecessary. 
This  was  a  very  long  and  tedious  process, 
and  the  prolongation  of  the  operation  and 
the  greater  loss  of  blood  appeared  to  me 
far  to  outweigh  any  advantages  gained 
by  diminishing,  by  a  few  inches,  the  length 
of  the  incision.  Still  it  is  not  always 
necessary  to  carry  the  incision  to  the 
extreme  border  of  the  tumonr,  as  an  oval 
tumour,  or  a  tumour  with  irregular  pro- 
jections;, may  often  be  so  turned  and 
pressed  out,  as  to  pass  without  force 
througli  a  much  smaller  opening  than 
Avould  at  first  sight  be  thought  possible. 

Adhesions  are  dealt  with  precisely  as 
in  ovariotomy.  The  chief  difference  ob- 
servable in  the  vascularity  is  that,  when 
the  tumour  is  covered  by  the  broad  liga- 
ment, the  veins  are  apt  to  be  much  larger. 
They  should  be  avoided  when  possible, 
or,  if  opened,  closed  at  once  by  pressure 
forceps. 


"When  a  long  incision  has  been  made, 
it  is  a  good  plan  to  pass  2  or  3  sutures 
near  and  above  the  umbilicus  as  soon 
as  the  tumour  has  been  brought  out,  in 
order  to  prevent  escape  of  intestine  be- 
fore proceeding  to  a  separation  of  the 
tumour.  The  mode  of  separating  the  tu- 
mour will  of  course  depend  upon  its  con- 
nections. When  there  is  a  distinct  pedicle, 
this  may  be  secured  exactly  as  in  ovario- 
tomy. When  there  is  no  pedicle,  many 
plans  of  treatment  are  open  to  us,  which 
will  be  described  in  one  or  other  of  the 
cases  I  am  about  to  relate.  The  remarks 
upon  the  after  treatment  of  cases  of  ovario- 
tomy are  equally  applicable  to  those  of 
myomotomy. 

SOLID  SUB-PERITONEAL  UTERINE  OUT- 
GROWTHS, TREATED  INTRA-PERITONE- 
ALLY 

Solid  tumour  ;  no  2^^dicle ;  ligature  ; 
death  from  ha'inorrhage. — In  the  case  of  a 
single  lady,  32  years  of  age,  upon  whom 
I  operated  in  December  1874,  removing 
a  solid  fibro-myoma  which  weighed  9 
pounds,  there  was  no  pedicle,  but  the 
tumour  appeared  to  be  a  prolongation 
of  the  fundus  uteri  tOAvards  the  right, 
forming  a  circular  neck  about  2  inches 
in  diameter.  This  was  transfixed  and 
tied  in  two  halves.  A  third  ligature  was 
put  on  below  the  others.  The  tumour 
was  cut  away,  and  the  uterus  then 
appeared  to  be  about  the  normal  size. 
It  was  returned  along  with  the  ligatures, 
just  as  in  ovariotomy.  The  patient  died 
40  hours  after  operation,  of  haemorrhage. 
The  ligatures  were  not  sufficiently  tight. 
I  suppose  that  the  uterine  tissue  had 
shrunk  soon  after  the  operation,  the 
ligatures  becoming  loose.  If  the  Avound 
had  been  reopened  and  fresh  ligatures 
applied,  life  might  have  been  saved.  The 
uterus,  as  well  as  the  tumour  removed, 
may  be  seen  in  the  Museum  of  the  Col- 
lege of  Surgeons. 

Solid  sub-peritoneal  outrjrowth ;  second 
tumour  not  removed ;  recovery. — I  do  not 
think  it  has  occurred  to  me  more  than 
twice  to  remove  an  outgrowth  from  the 
uterus,  and  then  find  that  there  were  other 
growths  which  could  not  be  removed,  or 
which  I  thought  it  more  prudent  not 
to  disturb.  Occasionally  a  second  growth 
has  been  removed,  and  in  other  cases 
there  lias  been  merely  felt  such  slight 
enlargement,    irregularity  of  surface,   or 


UTERIXJ':   TL'MOL'RS 


.147 


partial  hardening  as  led  me  to  believe 
that  there  might  be  some  small  inter- 
stitial fibroids.  In  the  two  cases  1  am 
about  to  mention,  the  growth  not  removed 
was  nearly  as  large  as  that  which  was 
taken  away.  The  first  was  in  December, 
1879,  with  Dr.  Godson,  who  had  recog- 
nised a  fibroid  outgrowth  from  the  fundus 
as  removable,  and  another  from  the  cervix 
or  body,  which  we  explained  to  the  patient 
Avould  probably  prove  to  be  irremovable. 
At  her  desire  1  removed  the  mobile  out- 
growth, applying  a  clamp  at  the  seat  of 
connection  between  the  fundus  and  the 
tumour,  before  cutting  the  tumoiir  away. 
Wishing  to  treat  the  pedicle  intra-peri- 
toneally,  I  tied  a  ligature  behind  the 
clamp,  but  it  cut  quite  through  the 
uterine  tissue,  and  the  clamp  came  off. 
There  was  no  bleeding,  and  I  did  not  apply 
another  ligature.  The  uterus  was  very 
irregular  in  form,  with  fibroid  projections 
in  different  directions.  Except  some  pro- 
trusion of  omentum  between  two  of  the 
stitches,  recovery  was  most  satisfactory. 
The  patient  has  remained  remarkably 
well,  Avithout  any  further  uterine  enlarge- 
ment. 

Tv:o  fibroids^  suh -peritoneal ;  one  re- 
moved, the  other  left;  2-)eritoneum  sewn 
over  surface  of  stumj). — The  other  case 
.in  which  I  removed  a  fibroid  outgrowth 
from  the  fundus,  about  the  size  of  a  fatal 
head,  leaving  undisturbed  a  considerable 
growth  attached  posteriorly  and  directed 
downwards  into  Douglas'  pouch,  was  a 
single  lady,  a  patient  of  Dr.  Ord.  In  this 
case  the  treatment  of  the  pedicle  was  also 
intra-peritoneal,the  edges  of  the  peritoneal 
coat  of  the  uterus  being  closely  brought 
together  by  uninterrupted  suture  over  the 
surface  where  the  tumour  had  been  cut 
aAvay.  This  patient  also  recovered  well, 
and  has  not  yet  suffered  from  any  en- 
largement of  the  growth  which  was  not 
removed. 

Solid  fihvo-myoma ;  ligatures ;  re- 
covery.— In  previous  cases  I  had  been 
content  with  the  pressure-forceps  described 
and  figured  in  the  '  British  I\Iedical 
Journal,'  vol.  i.  1879,  ji.  928 ;  but,  feel- 
ing the  want  of  more  effectual  means  of 
securing  bleeding  vessels  before  dividing 
them,  I  had  forceps  made  similar  in  form, 
but  with  longer  handles,  and  a  compress- 
ing surface  more  than  an  inch  in  length. 
With  several  pairs  of  such  forceps,  applied 
before  any  tissues  are  cut  through,  large 
tumours  may  be  cut  away  with  only  very  ^ 


small  loss  of  blood.    They  were  used  with 
excellent  effect  in  the  following  case. 

On  September  27,  l'S80,  assisted  by 
Mr.  Thornton  and  Mr.  A.  Doran,  I  re- 
moved a  large  solid  uterine  libro-myoma 
from  a  sin;i;le  lady,  aged  41.  By  an 
incision  8  inches  long,  the  tumour  was 
exposed,  or  rather  the  omentum,  contain- 
ing very  large  vein.s,  which  covered  the 
tumour  and  adhered  to  it.'  Two  ligatures 
were  applied  to  the  omentum,  wliich  was 
then  divided  between  them.  Some  ad- 
hesions to  the  abdominal  Avail  were  then 
separated,  and  the  tumour  turned  out 
entire.  It  Avas  a  solid  outgrowth  from 
the  left  side  of  the  fundus  uteri.  The 
band  of  connection  between  the  uterus 
and  the  outgrowth  Avas  between  2  and  3 
inches  in  length,  and  about  1  inch  in 
breadth.  This  Avas  first  compressed  and 
held  by  2  of  the  large  forceps  just  de- 
scribed, and  the  tumour  Avas  cut  away. 
Then  a  large  needle  Avith  double  thread 
Avas  pushed  throusrh  the  uterine  tissue 
behind  the  forceps,  and  each  thread  Avas 
tied  as  the  forceps  were  taken  off.  Lastly, 
the  peritoneal  edges  of  the  divided  uterine 
Avail  Avere  brought  together  by  an  un- 
interrupted suture  of  fine  carbolised  silk. 
After  the  removal  of  the  tumour,  the  rest 
of  the  uterus  appeared  to  be  quite  normal 
in  size  and  consistence.  Both  ovaries 
were  healthy.  Recovery  Avent  on  Avith- 
out  fever — the  highest  temperature  Avas 
1002°.  There  Avas  unusual  nervous 
irritability  during  convalescence,  perhaps 
explained  by  the  facts  that  her  father 
and  an  uncle  had  both  been  insane  and  • 
attempted  suicide  ;  but  she  Avent  aAvay 
30  days  after  operation  in  a  very  good 
state  of  health,  and  has  since  been  quite 
Aveil.  Mr.  Doran  described  the  tumour 
as  a  solid  uterine  fibro-myoma,  Aveighing 
between  7  and  8  pounds.  This  lady 
called  on  me  in  December  1884  in  excel- 
lent health.  The  catameuia  had  been 
quite  regular  until  October  1884.  The 
size  of  the  uterus  AViis  normal,  and  the 
only  cause  of  complaint  a  protrusion  of 
viscera  behind  the  thin  cicatrix  in  the 
abdominal  Avail. 

.SOLID    FIDROIDS,    SLT.-PEKITOXEAL  ;    TUEAT- 
MEXT    EXTUA-PEUITOXEAL 

Sub-peritoneal  fibroid  ;  clamp  ;  reco- 
very.— The  patient  Avas  single,  37  years 
of  age,  and  the  operation  Avas  performed 
in  April   1S7G.     The  tumour  was  a  solid 

L    2 


148 


UTERINE   AND   OTHER   ABDOMIXAL   TUMOURS 


fibroid  outgrowth  from  the  fundus  uteri, 
and  connected  Avith  it  by  a  pedicle 
about  2  inches  in  length  and  1^  inch 
in  breadth  and  thickness.  This  pedicle 
was  secured  in  a  middle-sized  clamp, 
■which  "was  kept  outside  without  much 
pull  upon  the  uterus,  simply  holding  it 
up  close  to  the  abdominal  wall.  Both 
ovaries,  Fallopian  tubes,  and  the  uterus 
appeared  to  be  quite  normal.  The  out- 
growth Avhich  Avas  removed  seemed  to  be 
the  only  part  diseased.  The  patient  has 
been  in  good  health  ever  since.  The 
tumour  was  a  solid  iibro -myoma,  which 
measured  25  inches  in  the  longer  and  13 
inches  in  the  shorter  circumference,  and 
is  preserved  in  the  Museum  of  the  College 
of  Surgeons. 

Sab-peritoneal  fibroid  ;  pins  and  liga- 
ture  acting  as  clamp  ;  recovery. — In  June 
1871  I  removed,  in  the  Samaritan  Hospi- 
tal, from  a  married  woman,  aged  40,  a 
solid  outgrowth  from  the  fundus  uteri, 
which  Aveighed  11  pounds  11  ounces,  and 
Avas  surrounded  by  59  pints  of  serous 
fluid.  The  neck  or  connection  between 
the  tumour  and  the  fundus  uteri  Avas  first 
compressed  by  a  large  ecraseur,  but  as 
this  Avas  tightened  it  cut  through  the 
uterine  tissue,  and  free  bleeding  had  to  be 
stopped  by  twisted  suture  over  long  pins, 
Avhich  were  afterwards  fixed  outside  the 
Avound  like  a  clamp.  On  the  0th  day 
these  pins  and  ligatures  came  away  ;  there 
Avas  free  bleeding.  On  tying  the  project- 
ing stump  the  ligature  cut  through  it,  bi;t 
the  bleeding  Avas  stopped  partly  by  per- 
chloride  of  iron  and  partly  by  tying  a 
vessel  over  a  tenaculum,  Avhich  did  not 
come  away  till  the  13th  day.  The  patient 
perfectly  recovered,  and  Avas  in  good  health 
in  thft  summer  of  1884. 

Tico  solid  fibroids ;  clamp  on  one, 
ligaim'C  on  the  other;  recovery. — I  removed 
two  solid  fibroid  outgrowths  from  the 
uterus  of  a  single  Avoman,  52  years  of  age, 
in  the  Samaritan  IIosj)ital,  April  1877. 
One  of  these  tumours  had  a  pedicle,  Avhich 
Avas  secured  by  a  clamp;  the  other,  which 
liad  no  pedicle,  Avas  removed  after  trans- 
fixion and  tying  the  connection  Avith  the 
uterus.  Each  of  these  groAVths  weighed 
a  little  more  than  4  pounds.  One  of  them 
Avas  partly  calcified.  A  third  outgrowth 
from  the  posterior  part  of  the  fundus, 
quite  low  down  in  Douglas's  pouch,  was 
not  disturbed,  as  it  Avas  not  larger  than  2 
Avalnuts  and  its  connection  Avas  broad. 
The  clamp  was  removed  on  the  0th  day, 


Avith  two  thick  silk  ligatures  and  a  slough 
through  Avhich  they  passed.  On  the  loth 
day  some  fetid  pus  escaped,  when  another 
slough,  about  l?y  inch  long,  AA-as  draAvn 
out.  The  patient  recovered  rapidly,  left 
the  hospital  Avithin  a  month  of  the  opera- 
tion, and  Avas  well  in  July  1878. 

Solid  fibroid ;  pins  and  ligatures  as 
clamp  ;  death  from  embolic  pneumonia. — 
In  June  1870  I  removed  a  solid  myoma, 
Aveighing  22  pounds,  from  a  .single  lady, 
3G  years  of  age,  Avho  died  14  days  after- 
Avards.  The  pedicle  Avas  treated  extra- 
peritoneally,  2  long  pins  and  a  ligature 
acting  as  a  clamp.  I  had  first  used  an 
ecraseur,  but  the  chain  cut  through  the 
uterine  tissue.  Very  free  bleeding  fol- 
loAved,  Avhich  the  actual  cautery  and  liga- 
tures fliiled  to  check.  The  patient  went; 
on  very  Avell  for  14  days,  and  then  she  died 
of  embolic  pneumonia.  It  Avas  most  dis- 
appointing, for  there  Avas  only  a  small 
superficial  abscess  in  the  abdominal  Avail, 
and  no  other  reason  to  account  for  the 
condition  of  lung  Avhich  caused  death.  I 
dressed  the  Avound  every  day,  and  had  not 
noticed  anything  indicating  this  collection 
of  pus.  But  she  became  feverish,  had 
symptoms  of  pyremic  pneumonia,  and  she 
died  owing  to  this  small  abscess  in  the 
abdominal  Avail;  for  inside  the  peritoneum 
eA'erything  Avas  absolutely  healed.  There 
Avas  nothing  about  the  uterus  to  attract 
attention.  Its  surface  Avas  quite  smooth, 
the  peritoneal  edges  of  the  incision  per- 
fectly united,  and  no  traces  Avhatever  of 
any  peritonitis. 

Solid  fibroid  ;  forciprcssnre  ;  no 
bleeding  ;  no  ligature. — In  September 
1870  I  drcAv  out,  by  tapping,  about  30 
pints  of  fluid  from  the  peritoneal  cav^ity 
of  a  Avidow,  52  years  of  age,  and  then 
found  a  solid  uterine  tumour  as  large  as 
a  foetal  head,  Avljich  I  removed  on  October 
15,  1S70,  Avith  I'S  pints  of  ascitic  fluid 
Avhich  had  again  accumulated.  The 
tumour  Avas  an  outgroAvth  from  the  fundus 
uteri,  Avith  a  pedicle  in  circumference  nor 
much  larger  than  half-a-crown,  but  only 
about  V,  an  inch  in  length.  This  Avas 
temporarily  secured  in  a  straight  screw 
forceps  and  the  tumour  cut  away.  On 
opening  the  forceps  nobleeding  took  place 
Irorn  the  pedicle.  The  vessels  had  been 
so  effectually  crushed  by  the  compression 
that  a  ligature  Avas  not  needed.  The 
tumour  itself  Avas  about  the  size  of  two 
fists.  It  Avas  not  Aveighed.  Both  o\-aries 
Avcre  n;irmal  and  tlie  uterus  also,  except 


J 


UTEllINE   TTjMOUKS 


149 


Tvliere  tlie  tuinonr  had  grown  from  the 
iundus.  The  patient  i-ecovered  admirably 
well.  It  was  remarkable  that  there 
was  no  re-formation  of  ascitic  fluid,  al- 
though before  the  operation  3  tappings 
had  been  necessary — one  hi  March,  1871), 
of  5  gallons ;  a  2nd  in  April,  of  3| 
.gallons ;  and  a  3rd  G  weeks  later,  of  5 
gallons;  and  fluid  to  the  amount  of  25  to 
30  ounces  daily  had  been  removed  after 
the  3rd  tapping  by  one  of  Southey's. 
capillary  tubes.  The  patient  was  reported 
to  be  wonderfully  well  in  January  1885. 
SoVul  Jibroid  from  fundus  ;  pin  passed 
tliroiif/h  stiniip  and  abdominal  wall ;  death. 
—On  April  7,  18G9,  I  exhibited,  at  a 
meeting  of  the  Obstetrical  Society  a  fibroid 
outgrowth  from  the  fundus  uteri,  weigh- 
ing 34  pounds  and  10  ounces,  which  I 
•had  removed  a  few  hours  before  from  a 
•single  woman,  36  years  old.  Eleven  years 
before,  half  her  lower  jaw  had  been  re- 
moved  Avith  a    fibrous    tumour    by    JMr. 


Pemberton  of  Birmingham.  An  abdo- 
minal tumour  was  discovered  in  1864;  it 
enlarged  gradually,  and  she  was  twice  in 
the  Birmingham  Hospital.  During  the 
last  6  months  the  tumour  had  increased 
rapidly,  and  she  became  very  weak  and 
lost  flesh.  On  admission  to  the  Samaritan 
Plospital  a  very  large  abdominal  tumour 
■could  be  felt,  but  it  evidently  contained 
no  cyst  large  enough  to  warrant  tapping, 
and  did  not  feel  so  hard  as  a  fibroid 
tumour  of  the  uterus.  No  vascular  mur- 
mur was  audible  in  it,  and  it  appeared  to 
move  quite  independently  of  a  uterus  of 
normal  size.  When  the  tumour  was  ex- 
posed I  was  surprised  to  find  that  it  was 
not  ovarian.  It  sprang  from  the  posterior 
.  surface  of  the   fundus  uteri  by   a  short 


pedicle,  as  shown  in  this  drawing  to  scale 
by  Dr.  Junker,  Avhich  represents  the 
posterior  surface  of  the  uterus,  with  the 
Fallopian  tubes  and  both  ovaries.  A 
rujitured  Graafian  vesicle  is  .seen  on  the 
left  ovary.  The  pedicle  was  secured  by 
a  clamp  forceps  and  the  tumour  was  cut 
away.  Some  bleeding  spots  where  ad- 
hesions had  been  sepaiated  were  secured 
by  an  acupressure  needle,  and  the  clamp 
was  removed.  Bleeding  vessels  were 
secured  by  hare-lip  pins  and  twisted 
sutures,  which  also  served  to  fix  the 
bleeding  surface  to  the  abdominal  wall  by 
transfixion.  The  patient  died  on  the  3rd 
day  alter  the  operation,  not  from  any 
bleeding,  peritonitis,  or  other  direct  con- 
sequence of  the  operation,  but  from 
fibrinous  deposit  in  the  right  side  of  the 
heart.  At  the  present  day  we  should  refer 
the  cause  of  death  in  this  patient  to  septi- 
cfemia,  and  believe  that  it  might  have 
been  averted  by  antiseptics. 

Dr.  Braxton  Hicks  reported  of  the 
tumour  that  '  it  was  about  17  inches  in 
diameter.  It  had  a  fiuctuation  very 
similar  to  tliat  of  an  ovarian  polycystic 
growth,  which  it  also  resembled  much  in 
appearance. 

'  The  interior  was  found  to  be  free 
from  cysts,  excepting  a  few  of  small  size, 
of  a  false  kind,  formed  by  separation  of 
the  layers  of  the  tissues,  the  largest  not  an 
inch  in  diameter,  of  irregular  form.  The 
tissue  of  which  it  was  composed  was 
arranged  in  a  manner  concentric  with  the 
true  centre,  except  in  the  lobules,  where 
it  was  arranged  around  the  centres 
differing  from  the  irregularly  concentric 
arrangement  generally  found  in  mural 
uterine  fibroid  growths.  When  cut  into, 
serum  exuded  rather  freely.  The  inside 
of  the  growth  was  of  a  pink,  semi-trans- 
lucent colour. 

'  The  microscopical  examination  of  the 
growth  i-howed  it  to  be  composed  of 
areolar  wavy  tissue,  interlacing  in  all 
directions,  but  the  arrangement  of  the 
fibres  was  very  open,  and  between  them 
the  serum  w^as  held  ;  very  little,  if  any, 
true  uterine  fibres  existed.' 

My  present  belief,  founded  on  later 
experience,  is  that  if  the  pedicle  or  con- 
nection Avith  the  fundus  uteri  had  been 
treated  either  j'«/r«-peritoneally  by  or- 
dinary or  elastic  ligature,  or  extra-pevl- 
toneally  by  a  clamp,  the  result  Avould 
have  been  better  than  by  the  combined 
method  adopted  of  securing  the  stump  to 


150 


UTERIXE   AND   OTHER   ABDOMINAL   TU.MOURS 


the  ahdominal  wall  by  a  pin  ■which  passed 
through  both  stump  and  ■wall. 

FIDRO-CYSTIC    UTERINE    TUMOURS 

Fibro  -  cijStic  outf/rowth  ;  l.'r/afure 
Ironrjlit  out  of  wound ;  daith. — In  the 
3rd  uterine  case  upon  which  I  operated 
in  18G3,  there  Avere  very  extensive  pa- 
rietal adhesions,  which  were,  however, 
easily  bioken  down.  Some  long  hands 
of  thickened  onicnttim  were  also  attached 
to  the  tumoiir,  but  the  closest  adhesion 
■was  to  the  right  iliac  fossa.  On  account 
of  this  close  adhesion  no  proper  pedicle 
could  be  defined.  A  thick  band  reached 
from  the  right  side  of  the  uterus  to  the 
tumour,  which  was  embraced  by  a  wide 
expansion  of  broad  ligament  that  blended 
Avith  the  adhesions  to  the  right  iliac  fossn. 
I  transfixed  below  the  Fallopian  tube,  tied 
and  cut  awa-y^  the  tumour.  I  then  tied  3 
large  arteries  in  the  Ibid  of  the  broad 
ligament,  and  2  on  the  surface  of  the 
stump.  The  left  ovary  could  not  be 
accurately  defined.  Two  small  fibroid  out- 
growths Irom  the  uterus  were  cut  aAvay ; 
one  of  them  was  the  size  of  a  filbert,  the 
other  of  2  walnuts.  They  bled  a  little 
at  first,  but  ceased  on  the  vessels  being 
compressed.  The  hremorrhage  during 
the  operation,  though  rather  iree,  was  by 
no  means  alarming ;  perhaps  G  or  8  ounces 
of  clot  may  liave  been  taken  from  the 
abdominal  cavity.  I  closed  the  wound 
with  6  deep  and  several  superficial  su- 
tures, and  brought  out  the  ends  of  the  liga- 
tures at  tlie  inferior  angle  of  the  wound. 
The  patient  died  in  a  few  hours.  Clot 
and  serum  were  found  in  the  pelvis.  The 
uterus  was  about  twice  its  natural  size. 
The  left  ovary,  slightly  enlarged,  retained 
its  natuial  connection  with  the  uterus. 
The  tumour  removed  was  a  fihro-cystic 
outgrowth  from  the  right  side  of  the 
fundus  of  the  uterus.  The  solid  fibroid 
mass  weighed  IG  pound.s  G  oiinces,  and 
the  large  cyst  had  held  2G  pints  of  fluid 
and  4  pounds  of  lumpy  masses  of  de- 
composed fibrine.  Tlie  right  ovary, 
slightly  enlarged,  adhered  to  the  outer 
surface  of  the  tumour. 

fII5R0-CY.STIC   OUTGROWTHS — INTRA- PERI- 
TONEAL ti;i:a'1.ment 

Fihro-cij^tic,  tumour;  ligature;  re- 
covery.— I  do  not  remember  to  have  seen 
more    than    1    case  where  a  fibro-cystic 


tumour  of  the  uterus  had  a  very  distinct 
pedicle.  I  removed  such  a  tumour  in 
December  1884  from  a  single  lady,  30 
years  of  age,  a  patient  of  Mr,  Aikin.  The 
tumour  was  a  fibroid  outgrowth  from  the 
fundus,  with  a  pedicle  about  the  length 
and  size  of  a  small  finger.  Near  the  pedicle 
the  tumour  was  quite  solid.     In  the  upper 


portion  ■were  several  cystlike  cavitie.'--, 
Avhich  contained  clear  reddish  fluid.  These 
Avere  tapped,  their  thin  membranous  coats, 
Avhich  adhered  to  the  inner  surface  of  the 
abdominal  Avail,  Avere  separated,  and  draAvn 
out  Avith  the  base  of  the  tumour  and 
the  pedicle.  This  Avas  transfixed  and  tied 
in  2  portions  Avith  silk  ligatures,  which 
Avere  cut  off  and  returned  after  dividing 
the  pedicle.  The  uterus  then  appeared 
to  be  of  normal  size,  and  both  ovaries 
Avere  normal.  The  patient  recovered 
Avithout  fever,  sickness,  or  pain,  and  the 
only  dressing  Avas  a  Aveek  after  the  opera- 
tion, Avhen  the  stitches  Avere  removed. 

Flbro-eiistic  uterine  tumour ;  lif/atures; 
recovery. — In  October  1879  I  treated  a 
much  larger  fibro-cystic  tumour  in  the 
same  AA-ay,  although  there  Avas  not  nearly 
so  distinct  a  pedicle.  The  solid  portion 
of  this  tumour  weighed  5  poimds,  and  the 
cystlike  cavities  contained  21  pints  of 
fluid  and  a  great  deal  of  old  blood-clot. 
The  patient  Avas  a  Dutch  lady,  40  years 
of  age.  There  Avere  extensive  adhesions 
to  the  abdominal  Avail,  to  omentum,  and 
to  several  coils  of  small  intestine.  The 
connecting  medium  betAveen  the  fundus 
uteri    and    the    tumour   Avas   first    com- 


UTEllINE   TUMOUnS 


101 


pressed  by  3  pairs  of  large  forceps.  After 
cutting  away  the  tumour,  the  stump  was 
transfixed  and  tied  in  two  parts,  as  the 
ibrceps  were  removed.  A  3rd  ligature 
was  afterwards  tied  round  the  other  2. 
The  ends  were  all  cut  off  close  to  the 
knots  and  returned  with  the  uterus, 
which  was  irregularly  enlarged  to  2  or  3 
times  its  normal  size.  Both  ovaries  were 
normal.  The  patient  recovered  Avithout 
one  bad  symptom,  and  returned  to  Holland 
24  days  after  operation.  I  heard  of  her 
in  August  lb84  as  quite  well. 

riDRO-CYSTIC     TUMOUnS,      TREATED     EXTRA- 
PERITONEALLY 

Fihro-ajstic  tumour  of  nterus ;  clamp  ; 
recovery. — In  the  case  of  a  German  lady, 
single,  40  years  old,  from  whom  I  removed 
in  May  1IS75  a  fibro-cystic  uterine  tumour, 
7v,  pounds  solid  with  ll^  iluid,  there  was 
u   sort  of  pedicle,  or  prolongation,  from 
the  left   side  of  the  fundus  uteri,  about 
3   inches  broad  and  |-  of  an  inch  thick. 
This  was  secured  in  a  large  clamp.     The 
patient  perfectly  recovered,  and  is  still  in 
good  health.     But  the  most  curious  point 
in  the  case  was,  tliat  about  6  hours  after 
the  operation  she  appeared  to  be  almost  { 
dead,  as  if  from  internal  bleeding.      On  I 
removing    one    of    the    stitches,    nothing  | 
but  red  serum  escaped.     This  continued  I 
to  flow  in   such    quantity   that   a   large 
drainage-tube   was    introduced,    through 
which  the  discharge  continued  to  be  very 
free  for  3  days.     The  tube  was  then  re- 
moved, biit  discharge  went  on  until  the 
clamp  was  found  loose  in  the    dressings  ; 
on  the   10th  day.     After  this  there  was 
gradual  improvement. 

Fihro-cystia  tumour;  clamp  ;  recovery. 
—On  July'24,  187X,  Mr.  Cowan  of  Bath 
wrote  to  ask  me  to  see  a  lady  who,  by 
his  desire  and  that  of  Dr.  Swayne  of 
Clifton,  was  leaving  for  London  that  day, 
in  order  to  consult  me.  The  next  day 
I  saw  this  lady,  39  years  of  age,  suffer- 
ing consideral)le  abdominal  pain  and  diffi- 
culty of  breathing  after  her  journey. 
She  had  been  married  4  years,  and  had 
not  been  pregnant.  The  catamenia  were 
regular,  and  a  period  was  due.  She  was 
suffering  so  much  that  I  did  not  make 
a  complete  examination ;  and  the  next 
day  the  suffering  was  so  great  that  I 
tapped  a  large  cyst,  felt  between  the 
ximbilicus  and  the  sternum,  and  removed 
19   pints  of  dark  fluid,   with   which   (as 


,  the  cyst  became  empty)  a  little  blood 
was  mixed.  A  large  semi-solid  tumour, 
\  reaching  a  little  above  the  umbilical  level, 
was  then  felt,  and  a  harder  portion  was 
I  found  in  the  right  iliac  fossa,  which, 
by  combined  external  and  internal  ex- 
amination and  the  use  of  the  sound,  was 
ascertained  to  be  the  uterus,  high  up  and 
to  the  right,  closely  connected  with  the 
lower  portion  of  the  tumour,  but  appa- 
rently separable  the  one  from  the  other. 

Mr.  Cowan  informed  me  that  the  ill- 
ness commenced  in  the  summer  of  1870, 
in  Italy,  Avhither  the  patient  had  gone  to 
recruit  after  great  mental  strain.  The 
first  symptoms  Avere  dull  pain  in  the  left 
iliac  region,  Avith  a  sense  of  fulness,  pain 
on  pressure,  and  constipation,  followed  by 
a  steady  increase  in  size  till  February 
1877,  when  he  (Mr.  Cowan)  found  '  fluc- 
tuation in  the  left  iliac  region,  and  a  solid 
tumour  passing  down  into  the  pelvis 
anterior  to  the  iiterus.'  There  was  steady 
but  slow  increase  ixntil  October  1877, 
when  sudden  painful  swelling  of  the  left 
leg  set  in,  with  acute  pain  in  the  left 
groin.  After  a  fortnight  this  subsided, 
but  the  cyst  increased  more  rapidly,  and 
a  solid  mass  was  found  to  the  right  of  the 
median  liup  in  the  umbilical  region. 
Dyspnoea  anu  general  distress  inci'eased, 
and  walkii-g  became  difficult. 

My  diagnosis  Avas  a  multilocular 
ovarian  cyst,  displacing  the  uterus  up- 
wards and  to  the  right.  This  Avas  con- 
firmed by  an  examination  of  the  fiuid  re- 
moved by  tapping,  by  Mr.  Thornton,  Avho 
reported  it  as  '  not  differing  in  any  way 
from  ordinary  ovarian  fluid,  except  the 
blood,  Avhich  is  fresh,  and  probably  from 
some  accidental  Avound  of  a  vessel.  Noav 
the  blood  has  settled,  it  looks  like  the 
ordinary  "  linseed-tea  "  fluid,  and  the  tests 
and  microscope  confirm  its  ovarian  cha- 
racters.' 

Great  relief  followed  the  tapping. 
The  catamenia  came  on  and  ceased  on 
Axigust  1.  But  the  fluid  began  to  collect 
again,  and  some  interference  Avith  respira- 
tion became  an  increasing  trouble.  Dr. 
Day  examined  the  chest  on  August  10, 
and  found  some  dulness  on  the  loAver 
part  of  the  left  lung,  Avhich  he  attributed 
to  pressure.  We  therefore  decided  on 
removal  of  the  tumour. 

I  j^erformed  the  operation  on  August 
12,  under  spray  and  Avith  strict  antiseptic 
precautions,  assisted  by  Dr.  Bantock,  Dr. 
Woodham  Webb,  and  Mr.  Cowan  of  Bath, 


152 


UTElfIXE   AND   OTHER   ABDOMINAL   TU3I0URS 


Dr.  Day  admiiiisterinir  methylene.  By  an 
incision  5  inches  long,  in  the  median 
line  between  the  umbilicus  and  symphysis 
pubis,  a  very  thin  cyst  was  exposed.  It 
was  bluish  in  appearance,  like  the  peri- 
toneum. On  tapping  it,  reddish  serum 
escaped.  Extensive  adhesions  to  the 
abdominal  wall  above,  and  to  the  intes- 
tines behind  and  to  the  left,  were  sepa- 
rated, and  the  empty  cyst  was  drawn 
out  with  a  mass  of  solid  substance  at 
its  base.  I  then  found  that  both  ovaries 
were  healthy  ;  that  the  uterus  was  about 
twice  the  normal  size,  irregularly  nodu- 
lated and  hardened  ;  and  the  tumour  was 
an  outgrowth  from  the  back  part  of  the 
fundus.  The  connecting  medium  or 
pedicle  was  fully  an  inch  in  length,  and. 
about  2  inches  in  breadth  and  1  in  thick- 
ness. I  .secured  this  in  a  large  clamp  and 
divided  the  attachment.  Then  1  had  to 
dissect  off  the  back  part  of  the  tumour 
from  the  sigmoid  flexure  of  the  colon  and 
from  the  rectum,  with  scissors.  In  doing 
this,  I  accidentally  made  an  opening  into 
the  upper  p  u-t  of  the  rectum,  about  an 
inch  long,  but  sewed  it  up  immediately 
with  an  uninterrupted  suture,  carefully 
sponged  out  the  peritoneal  and  pelvic 
cavities,  secured  seveial  bleeding  vessels 
in  parts  where  adhesions  had  been  sepa- 
rated, and  closed  the  wound  by  silk  sutures 
around  the  clamp,  which  lay  at  the  lower 
angle  of  the  closed  Avound. 

Dr.  Woodham  Webb  examined  the 
tumour,  and  reported  as  follows  :  '  Weight 
of  solid,  2^-  pounds ;  fluid  contents,  14 
pints.  The  tumour  wa.s  an  outgrowth 
Irom  the  upper  and  back  part  of  the 
uterus,  about  7  inches  long,  4  broad 
at  its  widest  part,  and  at  one  point 
2  inches  thick.  It  was  of  a  flattened 
lozenge  shape,  and  consisted  of  uterine 
tissue  very  .slightly  changed  in  appeai'ance. 
It  was  surroimded  liy  ,'5  large  c}  sts,  which 
had  developed  on  its  surface,  2  of  about 
equal  size  and  1  not  more  than  half  that 
of  the  others — the  -'i  having  contained 
14  pints  of  a  red  serous  fluid.  The 
walls  of  the  3  cysts  were  thin,  with 
a  fine  layer  of  muscular  tissue,  sj^read 
out  in  irregular  bundles  between  the  2 
serous  membranes — the  peritoneum  and 
the  cyst  lining.  Inside  the  cysts,  on  the 
solid  mass,  were  several  ecchymosed  spots, 
the  lining  membrane  being  detached  and 
giving  rise  to  .small  secondary  cysts.  There 
were  a  few  nodules  of  fibrous  tissue  in 
various  parts  of  the  cjst- walls.' 


The  progress  after  operation  was  one 
of  uninterrupted  recovery.  The  highest 
temperature  was  100"2°;  the  most  rapid 
pulse,  108.  The  clamp  came  off  on  the 
eighth  day.  The  wound  above  the  clamp 
healed  by  first  intention.  Thymol  gauze 
was  the  only  dressing  used. 

Writing  to  me,  December  5,  1878,  the 
patient  says :  '  I  am  wonderfully  Avell, 
and  am  getting  back  my  walking  powers. 
I  have  not  felt  so  well  nor  in  such  spirits 
for  years  past.'  She  was  still  quite  well 
in  the  summer  of  1881. 


SUPRA-VAGINAL    AMPUTATION    OF    UTEUUS 
WITHOUT    OPENING   THE    CAVITY 

Amjnif.aiion  ;  cavil;*/  not  opened  ;  inira- 
peritoncal  iif/atiire  ;  recovery. — In  a  case 
where  the  tumour  was  removed  without 
opening  the  uterine  cavity,  the  bleeding  was 
arrested  temporaxily  by  pressure- forceps. 
Ligatures  were  afterwards  tied  upon  all 
bleeding  vessels  as  the  forceps  were  re- 


moved, and  I  took  away  a  solid  fibrous 
tumour,  which,  after  about  3  pints  of  blood 
had  drained  from  it,  measured  2'J  inches 
in  the  longest,  and  24  in  the  shortest,  cir- 
cumference. I  performed  the  operation 
in  August,  1870,  at  Kidderminster,  assis- 
ted by  Mr.  Stretton.  The  right  ovary, 
wliich  had  adhered  to  the  outer  surface  of 
the  tumour,  was  cut  away.  The  uterus 
left  was  \cry  small,  and  its  cavity  was  not 


UTERINE   TUMOUES 


opened.  The  tumour  was  a  solid  mass  of 
dense  wliite  fibrous  tissue,  and  after  tlie 
greater  part  of  it  had  been  cut  away  its 
base  was  shelled  out  from  a  layer  of 
i;terine  tissue  about  a  third  of  an  inch 
in  thickness,  showing  that  the  fundus 
had  been  expanded  over  an  intra-mural 
fibroid.  This  patient  recovered  with  as 
little  illness  as  after  an  ordinary  ovario- 
tomy, and  has  remained  Avell. 

Amputation;  cavil ij  not  opened;  extra- 
peritoneal compression;  recovery. — I  ob- 
tained an  equally  successful  result  after 
removing  a  solid  fibroma,  weighing  30 
pounds,  nearly  circular,  measuring  40 
inches  in  the  longest  and  08  in  the  shortest 
circumference,  but  by  extra-peritoneal 
treatment.  I  operated  in  November  1884, 
assisted  by  Mr.  Meredith  and  Mr.  Jen- 
nings, The  incision  measured  11  inches. 
Extensive  parietal  adhesions  were  sepa- 
rated ;  two  pieces  of  adherent  omentum 
and  one  of  small  intestine  were  also  sepa- 


rated. A  broad  attachment  of  the  fundus 
iiteri  was  first  surrounded  by  an  elastic 
ligature.  The  tumour  was  then  cut 
through  about  2  inches  beyond  the  liga- 
ture, and  after  the  abdominal  wall  had 
been  nearly  closed  by  sutures,  the  base  of 
the  growth  was  shelled  out  from  the  ute- 
rine wall.  Doubting  Avhether  extra,  or 
intra,  peritoneal  treatment  of  the  stump 


would  be  preferable  in  this  case,  I  re- 
moved tlie  elastic  ligature.  Such  very 
free  bleeding  came  on  from  the  whole  of 
the  surface  from  which  the  growth  had 
been  shelled  out,  that  I  put  on  a  wire 
compressor,  and  fixed  the  stump  in  the 
lower  angle  of  the  wound.     I  also  fixed 


the  peritoneal  coat  of  the  uterus,  close  to 
the  compressing  wire,  to  the  peritoneal 
coat  of  the  abdominal  wall  on  each  side  of 
the  incision.  The  uterus  as  left  was 
rather  large  and  irregular  in  outline.  The 
ovaries  and  Fallopian  tubes  were  not 
touched.  Daily  tightening  of  the  wire 
compressor,  paring  aAvay  portions  of  the 
stump,  and  applying  perchloride  of  iron, 
made  a  very  tedious  contrast  with  cases 
treated  intra-peritoneally  ;  and  it  Avas  not 
until  the  28th  day  that  the  w^ire  could  be 
removed.  I  saw  this  patient  in  March 
1885.     She  Avas  quite  Avell. 

Amputation  ;  cavity  not  opened  ;  intra- 
peritoneal ligature  ;  recovenj. — The  next 
case  is  one  of  almost  unexpected,  but 
complete,  recovery.  In  May  1876  a 
married  lady,  aged  38,  called  on  me  Avith 
a  letter  from  Dr.  Birch,  of  Hazaribagh, 
in  India,  imder  Avhose  care  she  had 
been  since  May  1875.  She  Awas  married 
in  1871,  Avent  to  India  in  the  same  year, 
had  never  been  pregnant,  but  remained 
in  good  health  until  sne  suffered  from 
lever  in  September  1874.     In  February 


154 


UTEIIINE   AND   OTHER  ABD031INAL   TUMOURS 


1875,  Dr.  Ewart,  of  Calcutta,  discovered 
an  abdominal  swelling  which  he  thought 
might  poi'sibly  be  early  pregnancy,  al- 
though there  had  been  no  irregularity 
in  menstruation.  The  SAvelling  increased 
rapidly  in  1875,  and  when  I  saw  her 
in  May  187 G  the  uterus  was  evidently 
enlarged  to  the  size  in  the  fifth  or  sixth 
month  of  pregnancy.  As  there  were 
no  ui-gent  symptoms,  she  returned  to 
India,  and  I  did  not  see  her  again 
until  May  1877.  There  had  been 
some  slight  increase  in  the  size  o£  the 
uterus,  and  menstruation  was  becoming 
rather  profuse  ;  but  she  remained  in  fairly 
good  health  till  July  1878,  when  her 
general  health  suffered  after  much  anxiety 
and  over-exertion  ;  but  she  got  over  this, 
and  went  through  1879  pretty  well.  In 
June  18S0,  the  tumour  having  consider- 
ably increased  in  size,  Sir  W.  Jenner  saw 
her  with  me  in  cons»;ltation  as  to  the 
question  of  operation,  and  it  was  decided 
that  there  should  be  further  delay,  but 
that  the  tumour  should  be  removed  as 
soon  as  it  became  intolerable.  IMenstrua- 
tion  became  still  more  profuse,  size  in- 
creased, she  lost  fle.'-h,  became  imable  to 
take  any  but  very  short  walks,  the  feet 
swelled,  and  purpuric  spots  appeared  on 
the  legs.  In  December  1880,  at  another 
consultation  with  Sir  W.  Jenne::,  we 
found  a  large  solid  tumour,  reaching  quite 
up  to  the  ensiform  cartilage,  and  an  ovary 
could  be  felt  and  moved  in  each  iliac 
region.  The  uterine  cavity  was  slightly 
elongated,  but  I  thought  the  tumour  and 
part  of  the  fundus  uteri  might  probably 
be  removed  without  opening  this  cavity. 
It  was  agreed  tliat  I  should  attempt  to 
remove  the  tumour ;  but  that,  if  the  difli- 
culty  proved  to  be  greater  than  I  expected, 
I  should  then  remove  both  ovaries  in  the 
hope  of  thus  leading  to  atrophic  change 
in  the  tumoui-.  We  waited  Tuitil  after 
the  cessation  oi"  another  menstrual  period, 
and  I  then  wont  into  Gloucestershire,  and 
operated  on  February  12,  1881:  After 
making  an  incision  i'rom  2  inches  above 
to  G  inclu's  below  the  umbilicus  in  the 
median  line,  the  enlarged  solid  uterus  was 
exposed,  free  from  adhesions,  but  covered 
by  very  large  veins,  and  there  was  no 
distinct  neck  to  the  tumour  or  fundus. 
The  left  ovary  was  large,  and  both  were 
easily  separable  from  the  tumour.  My 
first  intention,  accordingly,  was  to  be 
satisfied  with  removal  of  both  ovaries,  and 
leave  the  uterus  alone.     On  drawing  up 


the  left  ovary,  a  cyst,  or  corpus  rubrum, 
in  it  burst,  and  much  black  clot  was 
pressed  out.  I  then  transfixed,  tied  the 
connecting  tissues  between  the  ovary  and 
the  enlarged  uterus,  and  cut  the  ovary 
away.  Very  free  bleeding  followed,  and 
successive  ligatures  cut  through  a  soft 
venous  plexus.  Itherelbre  felt  compelled 
to  remove  the  tumour,  and,  after  applying 
on  each  side,  before  and  behind,  4 
pairs  of  large  pressure-forceps,  I  ampu- 
tated the  tumour,  cutting  through  the 
fundus  uteri  diagonally  from  the  right 
Fallopian  tube,  downwards  and  to  the 
left  of  the  bleeding  surface,  where  the  leit 
ovary  had  been  attached.  The  uterine 
cavity  was  not  opened.  Part  of  the  fundus 
and  the  body  lel't  Avith  the  cervix  were 
normal  in  size  and  consistence.  The  left 
Fallopian  tube  was  removed  with  the 
tumour.  The  right  remained  ;  and  the 
right  ovary,  although  rather  large,  was 
not  disturbed.  Theoretically,  it  might 
have  been  better  to  remove  it ;  but  I  was 
very  unwilling  to  prolong  a  serious  opera- 
tion by  anything  not  absolutely  necessary. 
Several  very  large  arteries  and  veins  were 
secured,  some  by  ordinary  ligature  of 
carboliscd  silk,  some  by  ligature  after 
transfixing  the  uterine  tissvie  ;  and  then 
the  peritoneal  edges  of  the  divided 
fundus  Avere  brought  together  by  suture. 
Although  a  great  deal  of  blood  was  lost, 
the  lips  never  lost  their  colour,  and  there 
was  no  vomiting.  The  patient  was  exactly 
an  hour  imder  the  influence  of  the  anics- 
thetic,  and  Dr.  Day  told  me  that  he  had 
never  given  so  much  methylene  before  at 
any  of  my  operations.  Nearly  two  ounces 
were  used.  I  did  not  make  any  provision 
for  drainage,  as  I  had  carefully  sponged 
away  all  blood  and  clot;  and  the  wound 
was  -united  in  the  usual  Avay  by  silk 
sutures.  Phenolised  spray  was  used, 
phenolised  sponges,  ligatiu'cs,  and  instru- 
ments, and  dry  dressing.  The  tumour 
was  a  solid  fibroma,  with  several  projec- 
tions or  outgrowths  from  the  peritoneal 
surface.     It  weighed  llv>  lbs. 

The  patient  was  left  in  charge  of  Dr. 
Forty,  of  Wotton-under-Edge,  and  re- 
covery was  not  interrupted  by  any  bad 
symptom.  The  temperature  reached  101°, 
and  the  pulse  104,  on  the  third  day;  but 
the  convalescence  may  be  said  to  have 
been  without  fever.  I  saw  the  lady  in 
London  on  April  28th,  quite  well,  and 
with  nothing  but  the  linear  cicatrix  in  the 
abdominal  wall  to  be  detected  as  showing 


UTEEINE   TUMOURS 


155 


that  there  had  ever  been  any  disease  of 
the  iiterus.  The  cervix  was  mobile,  and 
nothing  abnormal  could  be  discovered 
anywhere.  The  catamenia  appeared  as 
usual  the  fii-st  Aveek  in  May,  after  an 
interval  of  three  months,  and  passed  olF 
normally.  The  lady  called  on  nie  in 
London  in  September  188-1,  having  con- 
tinued in  excellent  health,  menstruating 
regularly  luitil  the  end  of  1883. 

Amptitation  ;  cavity  not  opened;  intra- 
j)eritoneal  treatvient ;  recoi'>ery. — In  the 
following  case,  operated  on  June  27, 
18S1,  the  operation  might  have  been 
described  in  exactly  the  same  terms, 
except  that  the  left  ovary  v/as  left 
Avith  the  remnant  of  the  uterus  in  this 
case,  while  the  right  ovary  was  left  un- 
touched in  the  preceding  case.  Both  may 
be  described  as  supra-vaginal  amputation 
of  the  uterus  with  removal  of  one  ovary. 
The  lady  was  a  widow,  52  years  of  age, 
but  still  menstruating  regularly  and  pro- 
fusely, mother  of  4  children,  the  youngest 
of  whom  was  2G  years  old.  She  was  sent 
to  me  by  Dr.  Kidd  on  account  of  severe 
flooding  at  every  monthly  period,  which 
went  on  to  faintness,  and  was' followed  by 
extreme  exhaustion.  Sir  W.  Jenner  saw 
her  with  me  ;  and,  on  the  risk  of  the 
operation  for  the  removal  of  the  large 
uterine  tumour  being  explained  to  her, 
she  decided  to  wait.  She  went  to  Switzer- 
land, and  almost  died  at  Berne  from  very 
alarming  haemorrhage.  As  soon  as  she 
Avas  able  to  travel  she  returned  to  Eng- 
land, determined  to  submit  to  the  opera- 
tion which  I  have  already  alluded  to. 
The  recovery  was  i;n interrupted  except 
by  a  very  troublesome  irritation  of  the 
bladder.  She  Avas  obliged  to  travel  to 
Davos-Platz  in  October  1881  Avith  an 
invalid  relative,  and  although  she  suffered 
at  first  from  living  at  such  an  elevation, 
she  Avrote  to  me  on  December  15,  1881, 
saying,  '  The  pain  in  the  bladder  scarcely 
gives  me  any  trouble,  and  I  have  seen 
nothing  at  the  monthly  periods.  Indeed, 
the  only  inconvenience  arising  from  the 
operation  is  the  necessity  for  Avearing  a 
belt '  in  consequence  of  the  threatening  of 
a  ventral  hernia  at  a  Aveak  part  of  the 
cicatrix  in  the  abdominal  Avail.  This 
annoyed  her  so  much  that  in  the  summer 
of  1882  I  removed  the  bulging  part  of 
the  cicatrix,  Avhich  Avas  very  thin,  thus 
opening  the  peritoneum  for  about  2 
inches,  and  brought  the  edges  of  the 
opening  together  by  several  sutures.    No 


bad  symptom  folIoAved,  but  firm  union. 
No  truss  Avas  afterwards  necessary,  and 
I  saw  this  lady  in  November,  1884,  in 
excellent  health. 

Av^putation ;  cavity  not  opened;  death. 
— In  one  other  case  of  removal  from  a 
married  lady  35  years  of  age,  of  a  large 
solid  uterine  fibroma,  Aveighing  betAveen 
15  and  IG  pounds,  and  Avliich  had  been 
surrounded  by  ascitic  fluid,  I  have  to 
record  an  almost  sudden  death  from  shock 
and  haemorrhage.  The  patient  died  a  fcAv 
minutes  after  being  placed  in  bed.  Na 
very  great  amount  of  blood  was  lost,  but 
the  patient  took  methylene  very  badly, 
and  I  think  she  was  injuriously  affected 
by  the  cooling  influence  of  the  spray. 

Solid  outgroivth  from  fundus ;  cavity 
not  opened ;  intra-peritoneal  treatment  ; 
recovery. — Among  the  solid  tumours  re- 
moved, not  on  account  of  their  size,  but  be- 
cause of  the  extreme  suffering  they  caused ^ 
I  may  mention  the  case  of  a  married  lady 
40  years  of  age,  from  Avhom  I  removed,  in 
July  1882,  a  solid  outgrowth  from  the  fun- 
dus Avhich  Aveighed  only  a  pormd  and  a 
quarter.  She  was  married  Avhen  only  22 
years  of  age,  and  had  never  been  pregnant. 
The  catamenia  had  been  quite  regular,  but 
very  abundant,  and  lasting  about  7  days. 
She  had  suffered  for  many  years  from  ex- 
cessive pain  in  the  right  side  of  the  abdo- 
men and  right  loin,  which  had  been  attri- 
buted to  pressure  on  the  right  kidney  or 
ureter,  so  that  for  many  months  she  had 
been  obliged  to  take  on  an  average  150 
minims  of  Squire's  Solution  of  Bimeconate 
of  Morphia  daily.  In  the  intervals  between 
the  menstrual  periods  there  Avas  a  constant 
discharge  of  offensive  viscid  greenish  secre- 
tion, accompanied  by  great  depression  of 
spirits.  No  tumour  could  be  felt  by  the 
vagina,  but  a  solid  tumour  was  felt  in  the 
right  iliac  region  and  in  the  loin,  all 
movements  of  Avhich  immediately  caused 
corresponding  movements  in  the  cervix 
uteri.  The  uterine  cavity  Avas  not 
elongated.  After  exposing  this  tumour 
as  in  ovariotomy,  I  found  that  it  Avas  an 
outgrowth  from  the  fundus  uteri  toAvards 
the  right  side  above  the  Fallopian  tube. 
Temporarily  compressing  the  neck  by  tAVQ 
pairs  of  large  forceps,  as  shoAvn  in  the 
Avoodcut,  the  tumour  Avas  cut  aAvay  about 
half  an  inch  above  the  forceps.  Trans- 
fixing between  the  points  of  the  tAVo 
forceps  with  a  large  needle  carrying  a 
double  strong  silk  ligature,  each  ligature 
Avas  tightened  beloAV  the  forceps,  and  as 


106 


UTERINE   AXD   OTIIEll   ABDOMINAL   TUMOURS 


the  forceps  were  siiccessi%'^ely  removed  the 
ligatures  were  still  further  tightened  be- 
fore the  second  knot  was  made.  A  third 
ligature  was  then  applied  close  behind 
the  other  two.  The  peritoneal  edges 
of  the  stump  were  then  brought  to- 
gether by  a  few  points  of  uninterrupted 
suture  of  fine  silk.  The  uterus,  Fallopian 
tubes  and  ovaries  appeared  then,  with  the 
exception  of  the  sutured  spot,  to  be  cjuite 
normal.  Eecovery  was  uninterrupted  at 
first.  The  sutures  were  removed  on  the 
7th  day,  and  the  wound  appeared  to  be 
firmly  united,  but  on  the  following  day  she 
made  some  straining  effort  during  defeca- 


tion, the  wound  partly  reopened,  and  there 
was  a  considerable  escape  of  intestines. 
I  replaced  them  within  an  hour  o£  the 
accident,  inserted  fresh  sutures,  and  re- 
covery hardly  seemed  to  be  delayed.  All 
the  old  symptoms  disaj)peared,  and  the 
health  greatly  improved.  The  catamenia 
appeared  regularly,  but  there  has  been  fre- 
quent suffering  from  a  troublesome  neural- 
gic affection  of  the  bladder.  Neither  has  Sir 
Henry  Thompson,  who  carefully  examined 
her,  nor  have  I  been  able  to  discover  any 
cause  for  this  condition.     It  was  greatly 


relieved  this  summer  by  a  visit  to  Ems, 
and  though  still  coming  on  frequently  after 
passing  water,  she  has  been  able  entirely 
to  give  up  the  use  of  morphia. 

Fibroma  of  fundus  ;  cavity  not 
opened;  extra-peritoneal  treatment ;  death 
IHtli  day. — On  February  2,  1885,  assisted 
by  I\Ir.  Hough  and  Mr.  Green,  of  Derby, 
chloro-methyl  being  administered  by  Dr. 
Lathbury,  of  Breaston,  I  removed  from 
a  single  lady,  43  years  of  age,  a  myo- 
fibroma containing  a  cystlike  cavity  at 
the  upper  part,  which  had  caused  great 
suffering  for  many  years,  much  increased 
latterly.  There  Avas  no  pedicle.  The 
tumour  was  a  prolongation  of  the  fundus 
uteri  above  the  right  Fallopian  tube.  Two 
pins  were  passed,  as  shown  on  page  153, 
but  instead  of  the  wire  and  compressor,  an 
indiarubber  ligature  was  tied  behind  the 
pins,  and  the  stump  and  peritoneal  coat 
of  the  abdominal  wall  were  fastened  to- 
gether by  sutures.  The  patient  went  on 
remarkably  well  for  several  days  under 
Dr.  Lathbury's  care,  but  on  the  day  after 
the  sutures  were  removed  the  wound 
partly  reopened  and  intestines  escaped. 
Dr.  Lathbury  reapplied  the  sutures,  and 
the  accident  did  not  appear  to  have  done 
much  harm  ;  but  death  occurred  on  the 
LSth  day.  The  stump  had  separated 
three  or  four  days  previously. 

SUPKA- VAGINAL  AMPUTATION  OF  UTERUS  ; 
CAVITY  OPENED 

Solid  ahdomiaal  tumour ;  part  of  litems 
and  both  ovaries  re7noved ;  cavity  opened ; 
long  ligatures ;  death  4  days  afterwards. 
— On  September  9,  18G1,  1  was  consulted 
by  a  married  lady  from  Liverpool,  re- 
specting an  abdominal  tumour  which  gave 
her  the  appearance  of  being  quite  at  the 
end  of  pregnancy.  It  appeared  to  be  solid. 
The  girth  at  the  umbilicus  was  41  inches, 
the  measurement  from  pubes  to  umbilicus 
was  10  inches,  and  irom  umbilicus  to 
sternum  9  inches.  The  tumour  moved 
freely  beneath  the  abdominal  wall.  Pro- 
fessor Pirrie,  of  Aberdeen,  called  on  me 
during  the  first  visit  of  this  patient,  and 
saw  her  with  me.  She  told  us  she  was 
33  years  old,  had  been  married  14  years, 
but  had  never  been  pregnant,  and  had 
never  menstruated  before  her  marriage, 
nor  until  10  years  after  it.  Yet  for  the 
last  4  years  she  had  been  tolerably  re- 
gular, the  quantity  and  character  of  the 
discharcre  beino:   normal.      For   about   a 


UTERINE   TUMOURS 


■J  I 


week  before  each  period,  she  was  accus- 
tomed to  suffer  pain  in  the  back,  which 
lasted  during  tlie  fiow,  but  after  it  ceased 
she  was  always  decidedly  better  for  two 
or  three  weeks.  She  remarked  that  she 
was  larger  about  the  time  menstruation 
commenced,  but  attention  was  not  called 
to  the  abdomen  for  another  year.  Then 
she  began  to  lose  flesh  and  colour,  and 
Dr.  Battle,  of  Liverpool,  saAV  her.  For  12 
or  18  months  increase  was  slow.  In 
January  18G1,  she  became  seriously  ill, 
and  in  May  went  to  Dr.  Clay,  of  Man- 
chester, who  told  her  that  she  had  ovarian 
disease  in  an  advanced  stage,  but  advised 
delay  on  account  of  the  solidity  of  the 
tumour.  I  also  thought  the  tumour  was 
ovarian,  biit  its  extreme  solidity  led  me 
to  explain  to  the  patient  that  a  large  in- 
cision would  be  necessary  for  its  removal, 
and  that  therefore  the  operation  would  be 
additionally  hazardous.  Professor  Pirrie 
concurred  with  this  opinion.  She  re- 
turned to  Liverpool,  but  suffered  so  much 
that  she  returned  to  town  in  October 
detei-mined  to  have  the  tumour  removed. 
I  then  became  more  doubtful  as  to  its 
nature,  but  even  more  convinced  than 
before  from  its  mobility  that  it  could  be 
taken  away,  and  I  operated  on  October  14, 
1861.  Mr.  Cooke,  of  Charlwood.  Street, 
gave  chloroform,  and  I  was  assisted  by 
Mr.  Henry  Smith  and  Dr.  Rogers.  By  an 
incision  10  inches  long,  from  2  inches 
above  the  umbilicus,  a  solid  non-adherent 
tumour  was  exposed  and.  turned  out 
without  difficulty.  It  proved  to  be  a 
fibroid  outgrowth  from  the  fundus  of  the 
uterus,  and  I  passed,  the  chain  of  an 
ecraseur  around  a  sort  of  stem  just  where 
the  body  of  the  uterus  becomes  continu- 
ous with  the  cervix.  As  the  chain  was 
tightened,  the  shaft  of  the  instrument 
bent,  and  it  became  useless.  I  therefore 
substituted  for  it  a  very  large  clamp,  and 
cut  the  tumour  away.  Some  oozing  of 
blood  from  the  cut  surface  of  the  stump 
led  to  a  further  tightening  of  the  clamp, 
when  the  instrument  broke,  and  we  had 
copious  haemorrhage  from  very  large 
vessels.  But  they  were  all  tied,  and  the 
wound  was  closed  by  pins  and  sutures, 
the  ligatures  being  iDrought  out  at  the 
lower  angle. 

The  tumour  was  quite  solid,  and 
weighed  27  pounds.  It  consisted  of  the 
fundus  uteri  greatly  enlarged,  with  both 
Fallopian  tubes,  and  with  both  ovaries, 
about  twice  the  natural  size,  adherinor  one 


on  each  side  of  the  uterus,  and  contain- 
ing clots.  The  growth  of  tlie  fundus,  while 
the  cervix  remained  of  the  natural  size, 
had  led  to  a  sharp  line  of  demarcation,  or 
deep  sulcus,  in  (he  body  of  the  uterus. 
It  was  here  that  the  separation  had  been 
effected,  .so  that  the  os  and  cervix  felt 
perfectly  normal  after  the  operation. 

The  patient  rallied  tolerably  well 
after  the  operation,  and  became  fairly 
comfortable  in  the  afternoon  after  2  opiate 
enemas,  and  passed  a  pretty  good  night. 

On  the  first  day  after  operation  she 
was  pretty  well  all  day  ;  warm  and  per- 
.spiring;  the  pulse  from  110  to  120; 
some  tympanites,  but  no  vomiting,  and 
having  a  natural  quantity  of  urine  re- 
moved by  catheter.  Towards  evening 
the  p;dse  became  feebler,  and  there  was 
some  dyspnoea  with  somnolence,  althouo-h 
no  opium  had  been  given  since  the  morn- 
ing. Beef-tea  was  injected  into  the 
rectum.  On  the  second  day  she  was  said 
to  have  had  a  good  night,  sleeping  a 
good  deal,  but  the  pulse  was  130,  and 
occasionally  intermitted.  She  had  also 
vomited  2  or  3  times  during  the  night. 
Her  aspect  was  good,  the  skin  comfortably 
warm,  and  she  had  no  pain,  but  com- 
plained of  great  Aveakness.  In  this  state 
she  continued,  most  assiduously  supported 
by  Mr.  Cooke,  but  continuing  to  get 
weaker  and  weaker,  until  she  died  4  days 
after  the  operation.  No  post-mortem  ex- 
amination Avas  permitted. 

Amputation ;  cavitij  opened ;  death  6 
months  after. — In  one  case  I  removed 
the  fundus  and  body  of  the  uterus,  en- 
larged to  the  size  of  an  adult's  head,  by 
Avhat  we  believed  at  the  time  to  be  an 
innocent  myoma.  The  patient  recovered 
Avell  from  the  operation,  but  died  6  months 
afterwards  of  cancer  of  the  cervix.  The 
operation  Avas  performed  in  May  1869. 

Amputaiion;  clamp  and  ligatv7-e ;  re- 
covery.— The  next  case  Avas  treated  extra- 
peritoneally  by  the  clamp.  I  operated  at 
the  Samaritan  Hospital  in  April  1874. 
Dr.  Keith,  of  Edinburgh,  and  Dr.  Made- 
lung,  of  Bonn,  Avere  present.  The  patient 
had  been  married  7  years,  Avas  33  years, 
of  age,  but  had  never  been  pregnant. 
The  operation  Avas  begun  as  an  ordinary 
ovariotomy.  A  solid  tumour  Avas  covered 
by  omentum,  the  veins  of  Avhioh  Avere 
very  large.  On  pushing  this  aside  the 
peritoneum  Avas  seen  to  be  studded  all 
over  Avith  small  hard  bodies  like  mustard 
seeds.       After     separating,    tying,     and 


158 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


dividing  the  shreds  of  omentum,  the 
tumour  was  brought  out  entire.  Its  base 
or  neck  was  secured  in  the  largest  size 
clamp,  which  was  fixed  outside.  On 
cutting  away  the  tumour  just  above  the 
clamp,  I  found  that  I  had  cut  through 
the  uterine  cavity,  which  was  in  the 
centre  of  the  fibroid  mass.  The  right 
ovary  Avas  just  below  the  clamp.  This, 
with  the  tube,  was  secured  by  a  double 
ligature,  which  was  tied  to  the  arc  of  the 
clamp.  Part  of  the  stump  which  pro- 
jected above  the  clamp  was  then  cut 
away,  and  was  found  to  include  the  uterine 
cavity  quite  down  to  the  neck,  so  that  the 
clamp  must  have  compressed  part  of  the 
cervix  uteri.  The  tumour  was  a  fibro- 
myoma  which  weighed  11-^  pounds.  The 
clamp  did  not  come  off  till  the  15th  day, 
and  part  of  the  double  ligature  not  till  the 
oOth  day  after  the  operation.  The  patient 
went  home  well  in  6  weeks,  and  Mr. 
Soper,  of  Dartmouth,  wrote  to  me  in 
July  1.S78  that  she  had  enjoyed  good 
health  since  the  operation. 

Amputation;  cavitij  opened  ;  death. — 
In  one  case  which  I  operated  on  in  July 
1877,  removinga  uterine  fibroid,  weighing 
12  pounds,  and  both  ovaries,  the  uterine 
cavity  being  in  the  middle  of  the  tumour 
the  treatment  was  extra-peritoneal,  a  long 
needle  with  an  ecraseur  chahi  behind  it 
acting  as  a  clamp.  The  patient  died  on 
the  3rd  day,  of  septicaemia. 

Between  1H78  and  1880  I  adopted  2 
important  modifications  in  the  operative 
procedure — first,  the  more  complete  use 
of  antiseptic  precautions ;  and,  secondly, 
the '  union  by  suture  of  the  peritoneal 
edges  of  the  divided  viterine  wall.  I  also 
contrived  better  pressure-forceps  for  se- 
curing divided  blood-vessels  before  tying. 
In  a  paper  read  at  the  Cambridge  meet- 
ing of  the  British  Medical  Association,  in 
August  18,S0,  and  published  in  the  Joiu-nal 
of  the  Association,  September  4,  1880,1 
said,- '  Whatever  doubt  some  may  entertain 
as  to  the  value  of  my  experiments  on 
animals,  and  practice  on  women,  in  leading 
most  operators  in  the  present  day  to  bring 
divided  edges  of  peritoneum  together 
whenever  they  have  been  separated  by 
wound  or  by  operation,  I  myself  have  no 
doubt  whatever  about  it ;  and  just  as 
strongly  as  I  assert  that  it  is,  .and  must  be, 
better  Avhen  theal)dominal  wall  is  divided 
to  bring  the  ])eritoneal  edges  and  surfaces 
of  the  opening  together,  restoring  the 
complete  closure  of  the  peritoneal  cavity. 


than  to  leave  the  cavity  free  to  the  ad- 
mission of  fluids  oozing  from  wounded 
muscle,  fat,  and  cellular  tissue,  and  to 
allow  contact  of  intestine  and  omentum 
with  anything  more  than  peritoneum  ;  so 
strongly — more  strongly  if  I  could — would 
I  insist  that  the  peritoneal  edges  of  the 
divided  uterine  wall,  or  of  the  connecting 
part  of  the  outgrowth  Avith  the  uterine 
wall,  should  also  be  carefully  brought 
together  ...  by  many  sutures,  or  by  un- 
interrupted suture  along  the  whole  extent 
of  the  gap.'  In  concluding  that  paper  I 
alluded  to  a  case  then  under  observation, 
wliich  I  brought  forward  partly  to  illus- 
trate the  advantage  of  completely  uniting 
by  suture  the  divided  edges  of  the  peri- 
toneal wall,  and  partly  to  argue  that,  when 
the  uterine  cavity  has  been  opened,  it  is 
better  not  to  close  the  raucous  surfaces 
also  by  sutures,  after  the  method  of 
Schroder,  as  the  opening  left  for  some  oozing 
of  blood  through  the  vagina  may  some- 
times be  useful.  A  few  more  details  of 
this  case  may  be  now  given. 

Amputation;  cavitij  opened;  i^eritoneum 
sewn  over  stump  ;  recover//.— On  June  9, 
1880,  I  saw  a  married  lady,  aged  G2,  in 
consultation  with  Dr.  Richard  Smith,  of 
TIaverstock  Hill,  who  had  been  called 
in  about  a  fortnight  before,  on  account 
of  uterine  hemorrhage.  This,  alter  12 
years'  absence,  had  come  on  at  the  end  of 
1879,  and  had  recurred  since  every  3 
weeks,  lasting  1  week.  She  had  consulted 
an  obstetric  physician  4  years  before,  who 
said  that  there  was  'ovarian enlargement.' 
She  had  been  married  twice,  had  1  child 
by  her  first  husband  29  years  ago,  and 
had  never  been  pregnant  since.  With  the 
return  of  the  uterine  ha;morrhage  there 
occurred  'enlargement  of  the  abdomen, 
Avhich  increased  rapidly,  loss  of  flesh, 
shortness  of  breath,  and  very  obstinate 
constipation.  The  girth  of  the  abdomen 
at  the  most  prominent  part  was  42  inches. 
Tlie  uterine  cavity  only  measured  2^ 
inches,  but  the  cervix  moved  in  all  direc- 
tions with  a  large  semi-solid  tumour, 
which  filled  the  whole  abdomen  quite  up 
to  the  ensiform  cartilage.  I  removed  the 
tumour  on  July  21,  1880,  cutting  away 
nearly  all  the  supra-vaginal  portion  of  the 
uterus,  and  after  tying  all  bleeding  vessels, 
carefully  sewing  together  the  peritoneal 
edges  of  the  divided  uterine  wall.  For 
about  3  days  afterwards  a  little  bleeding 
went  on  through  the  vagina,  but  the 
patient  recovered  Avilhout  any  iebrile  ele- 


UTERINE  TUMOURS 


159 


vation  of  temperature,  was  in  excellent 
health  in  iSHl,  and  so  remains.  The 
doubt  as  to  the  tumour  being  ovarian  was 
accounted  for  by  the  fact  that  a  large  cyst- 
like cavity  in  the  centre  of  the  tumour 
contained  13  pints  of  bloody  fluid,  while 
the  solid  portion  weighed  only  a  little 
more  than  2  pounds.  I  am  much  indebted 
to  Dr.  K.  Smith  for  his  assistance  at  this 
operation,  and  for  his  care  of  the  patient 
afterwards,  as  she  remained  in  his  charge 
during  my  absence  irom  London, 

Supra-vnr/inal  amputation  ;  peritoneum 
sewn  over  cut  surface ;  death  on  dth  day. 
— The  relative  value  of  extra-peritoneal 
and  intra-ppritoneal  treatment  of  the  pedi- 
cle of  uterine  tumours,  or  of  the  divided 


vessels  as  they  were  divided  in  cutting 
away  the  uterus.  The  vessels  were  after- 
wards tied  as  the  forceps  were  removed. 
The  uterine  cavity  had  been  cut  through 
about  the  level  of  the  os  internum,  but 
the  peritoneal  surfaces  were  so  sewn  to- 
gether by  uninterrupted  silk  suture  as  to 
perfectly  shut  off  communication  between 
the  peritoneal  cavity  and  the  vagina. 
The  patient  died  on  the  9th  day,  of 
septicaemia. 

Supra-vaginal  amputation  of  the  uterus 
ivith  2  tumours  ;  extra -peritoneal  treat- 
ment;  recovery. — In  March  1884  I  ope- 
rated upon  a  lady  34  years  of  age,  who 
had  been  married  2  years,  but  had  not 
been  pregnant.  She  was  in  extreme  suffer- 
ing from  2  solid  tumours,  1  of  Avhich  was 
freely  movable  in  the  abdomen,  extended 
over  the  left  side  up  to  the  left  false  ribs, 


surface  from  Avhich  the  tumour  has  been 
cut  away,  or  of  the  body  of  the  uterus 
itself  in  cases  of  supra-vaginal  amputa- 
tion of  the  enlarged  uterus,  with  or 
Avithout  one  or  both  ovaries,  cannot  yet 
be  estimated  with  anything  approaching 
to  certainty.  Cases,  both  tatal  and  suc- 
cessful, may  be  adduced  in  favour  of  both 
methods,  and  of  different  modes  of  carry- 
ing out  the  details  of  each  method.  In 
one  case,  whei'e  I  removed  tbe  whole  of 
the  supra- vaginal  portion  of  an  enlarged 
uterus  with  fibroid  outgrowths,  both  Fal- 
lopian tubes  and  ovaries,  in  Jul}''  1873, 
Dr.  Martin  Sims  and  his  son  being  present, 
I    secured   by   forceps   all   the    bleeding 


and  could  be  felt  in  the  pelvis  between 
the  uterus  and  the  bladder.  The  other, 
much  smaller,  was  low  down  in  Douglas's 
pouch,  considerably  encroaching  upon  the 
rectum.  The  larger  tumour  to  the  left 
I  found  was  formed  by  the  fundus  uteri 
irregularly  eidarged.  The  smaller  tumour 
behind  and  to  the  right  was  an  outgrowth. 
Both  were  drawn  out  together  ;  a  wire 
was  passed  round  the  uterus,  just  below 
the  outgrowth  but  above  the  bladder,  and 
tightened  by  a  screw.  Two  long  pins 
were  pushed  through  the  neck  of  the 
tumour  above  the  Avire,  and  the  tu- 
mours were  cut  away.  The  incision 
went  through  the  uterine  cavity,  near  the 


IGO 


UTErJXE   AND   OTHER   ABDOMINAL   TUMOURS 


internal  os.  I  did  not  disturb  the  ovaries. 
In  uniting  the  incision  in  the  abdominal 
wall,  the  lower  suture  wag  passed  through 
the  peritoneal  coat  o£  the  uterus,  close  to 
the  constricting  wire.  The  mass  removed 
weighed  5  pounds  7  ounces.  The  patient 
recovered,  but  it  was  more  than  a  fort- 
night before  the  pins  and  wire  came 
away,  and  whenever  the  wire  was  tight- 
ened she  complained  of  extreme  pain. 
Before  the  cicatrisation  of  the  wound  was 
complete,  a  uterine  sound  could  be  ea.sily 
passed  from  the  lower  angle  of  the  un- 
clo.sed  wound  through  the  os  uteri  into 
the  vagina.  I  saw  this  lady  in  September 
1884,  well  and  strong,  not  having  had 
any  return  of  menstruation  or  periodical 
trouble  of  any  kind,  although  neither  of 
her  ovaries  had  been  interfered  with,  and 


there  Avas  nothing  in  the  condition  of  the 
cervix  uteri,  nor  anything  which  could  be 
Ifelt  by  vaginal  examination,  which  would 
have  led  anyone  ignorant  of  what  had 
been  done  to  suppose  that  the  pelvic 
organs  were  other  wiso  than  perfectly 
normal. 

EXUCLEATIOX 

Retro-peritoneal  turanur ;  enucleated; 
recovery. — A  remarkable  case  was  that  of 
a  lady  whom  I  saw  in  consultation  with 
Mr.  Symonds,  oE  Oxford,  in  February 
1878.  She  was  single  and  3G  years  of  ase. 
Her  abdomen  was  enormously  enlarged 
by  a  solid  tumour,  which  extended  up- 
ward behind  the  lower  ribs  on  both  sides, 
pressing  them  outwards,  and  passed  down- 


wards into  the  pelvi.=,  filling  up  the  hollow 
of  the  sacrum  and  causing  prolapsus  of 
the  posterior  wall  of  the  vagina.  There 
was  considerable  oedema  of  the  feet  and 
legs,  which  was  said  to  disappear  for  a 
time  after  the  cessation  of  each  monthly 
period.  The  cervix  uteri  could  not  be 
reached,  and  it  was  impossible  to  ascer- 
tain where  the  uterus  was  situated.  The 
catamenia  were  regular  in  time  and  normal 
in  quantity.  Mr.  Symonds  had  advised 
removal  of  the  tumour  in  187G  when  it 
was  much  smaller,  but  the  patient  and 
her  friends  steadily  objected.  The  first 
.symptom  of  illness  was  in  18G8,  when 
backache  became  troublesome,  and  soon 
after  a  small  tumour  was  discovered  in 
the  left  side  of  the  abdomen.  The  growth 
went  on  slowly  for  some  years,  but  in 
1877  was  much  more  rapid.  When  the 
patient  came  under  our  observation  in 
February  1877,  I  expressed  my  opinion 
to  Mr.  Symonds  that,  as  the  tumour  Avas 
quite  solid,  not  fluctuating,  and  as  the 
uterus  could  not  be  found,  an  accurate 
diagnosis  was  impossible,  and  that  only  an 


'  exploratory  incision  could  determine  as  to 
the  possibility  of  removal.     I  thought  the 
j  tumour  more  likely  to  be    uterine  than 
I  ovarian,    and    probably   some    such  rai-e 
I  form  of  abdominal  fibroma  as  I  had  once 
;  removed  in  Germany,  and  which  has  been 
I  described  by  Virchow  as  fibroma  molliis- 
cum,  not  necessarily  connected  with  either 
'  uterus    cr    ovaries.     The    decision  as    to 
operation  being  left  to  the  patient,  she  at 
first  declined,  but  suffering  became  daily 
greater,  and  it  Avas  arranged  tiiat  I  should 
make  an  exploratory  incision  on  IMarch  7, 
four  days  after  the  cessation  of  the  cata- 
menia. 

The  sketch  above,  although  made  of 
another  patient,  gives  an  excellent  idea  of 
the  appearance  of  this  lady  at  the  time, 
except  that  it  hardly  shows  how  much  the 
tumour  encroached  on  the  thorax,  and  not 
at  all  the  oedema  of  tlie  legs. 

Mr.  Symonds  and  Mr.  Hill  being  pre- 
sent, an  incision  Avas  made  in  the  median 
line  between  the  umbilicus  and  pubes, 
and  I  cut  into  the  substance  of  a  solid 
tumour  Avhich  was  closely  adherent  to  the 


UTERINE   TUMOURS 


IGl 


abdominal  wall.  After  separating  some 
adhesions,  I  passed  my  hand  into  the 
peritoneal  cavity  and  found  the  tumour 
to  be  free  from  adhesions  on  the  left  side, 
also  behind  and  above,  but  to  be  closely 
l)Ound  down  on  the  right  side.  In  i'ront, 
the  bladder  was  so  high  that  the  incision 
could  not  be  carried  within  about  4  to  5 
inches  of  the  pubes.  So  it  was  extended 
upwards,  about  5  or  G  inches  above  the 
umbilicus,  as  soon  as  I  had  convinced  my- 
self that  it  would  be  possible  to  remove 
the  tumour.  A  large  piece  of  adhering 
omentum  was  detached  from  the  upper 
part  and  behind.  Towards  the  left  side  a 
broad  mesenteric  attachment  was  divided 
by  the  knife,  large  vessels  being  tempo- 
i-arily  secured  by  torsion-forceps.  I  was 
then  able  to  shell  out  the  tumour  from  a 
sort  of  vascular  capsule,  formed  by  two 
layers  of  the  right  broad  ligament,  and 
separate  it,  but  only  by  the  knife,  from 
the  posterior  surface  of  a  uterus  of  normal 
size,  after  forcibly  pulling  the  tumour  up 
out  of  the  pelvis  and  separating  it  from 
the  rectum,  to  which  it  adhered  closely. 
The  right  ovary  (although  normal)  was 
cut  away  because  the  Fallopian  tube  had 
been  divided  and  the  broad  ligament  was 
much  torn.  The  left  ovary  and  Fallopian 
tube  were  not  disturbed.  Several  silk 
ligatures  were  applied  to  the  right  of  the 
uterus,  and  also  to  open  vessels  on  its 
posterior  surface  Avhere  the  tumour  had 
been  cut  away.  Two  large  pieces  of 
omentum  Avere  cut  off  after  securing 
them  by  ligature.  I  then  found  that  the 
two  opposite  sides  of  the  remnant  of  the 
capsule  of  the  broad  ligament  (out  of 
Avhich  I  had  enucleated  the  tumour)  could 
be  brought  together  behind  the  uterus,  so 
as  to  complete  the  union  of  the  divided 
peritoneum  from  the  lower  angle  of  the 
opening  in  the  abdominal  wall,  over  the 
elevated  bladder  and  the  fundus  uteri, 
all  down  the  back  of  the  uterus  to  the 
rectum.  I  did  this  by  an  uninterrupted 
suture  of  fine  silk,  making  about  20 
points  of  suture,  and  finishing  close  to 
the  vagina  and  rectum.  In  this  way  the 
peritoneal  sac  was  completely  shut  off 
from  the  torn  cellular  tissue  of  the  pelvis. 
A  good  deal  of  spongmg  Avas  necessary  to 
remove  clots  of  blood  from  the  peritoneal 
cavity ;  but  very  little  blood  was  lost 
considering  the  great  size  of  tiie  tumour 
and  the  extent  of  its  attachments.  The 
opening  in  the  abdominal  wall  was  closed 
by    25    silk    sutures.     The    patient    was 


placed  in  bed  exactly  an  hour  fiom  tlie 
minute  Avhen  she  began  to  inhale  methy- 
lene. She  was  faint  and  very  chilly,  a 
spray  of  a  solution  of  thymol  (1  in  1,000 
of  water)  having  played  upon  the  abdo- 
men all  through  the  operation;  and,  al- 
though sponges  moistened  with  warm 
thymol  solution  protected  the  abdominal 
cavity  to  some  extent,  the  chilling  effect 
of  the  spray  was  manifest. 

Upon  examining  the  tumour  it  was 
found  that  about  2  pounds  of  blood  had 
drained  from  the  vessels  divided  in  its 
capsule,  and  at  its  line  of  separation  from 
the  uterus.  Its  circumference,  in  o 
different  directions,  was  52  inches  at  the 
smallest,  57  inches  at  the  largest,  and  53 
inches  in  a  third.  A  small  piece  was  cut 
out  for  microscopical  examination,  and 
the  tumour  Avas  then  Aveighed  in  the 
museum  of  the  JMiddlesex  Hospital,  and 
found  to  be  G8  pounds  6  ounces.  The  tu- 
mour Avas  '  chiefly  composed  of  cells  Avith 
relatively  large  nuclei,  many  containing 
several  nucleoli  of  the  type  difficult  to 
distinguish  as  distinctly  muscular;  but 
in  some  parts  cf  the  tumour  imstriped. 
muscle-ceils  Avere  manifest.'  (J.  K. 
Thornton.)  I  have  A^ery  little  to  add. 
as  to  the  progress  after  operation,  except 
that  the  temperature  seldom  rose  above 
99°,  only  reaching  101-2°  (the  highest 
noted)  once.  Only  4  opiates  Avere  given. 
There  Avas  never  any  distension  of  the 
abdomen.  Six  days  after  operation,  the 
bandage  and  dressing  Avere  removed  for 
the  first  time.  The  4  or  5  layers  of 
thymol  gauze  next  the  skin  were  damp 
with  serum;  the  outer  layers  were  quite 
dry.  The  wound  A\-as  united,  from  top  to 
bottom.  All  the  25  sutures  were  removed, 
and  the  line  of  union  Avas  almost  imper- 
ceptible. The  dressing  Avas  only  changed 
twice  after  this;  and,  except  a  feAV  drops 
of  pus  from  one  of  the  central  stitchholes, 
union  Avas  perfect  by  first  intention. 

For  a  few  days  in  the  2nd  and 
3rd  Aveek  after  operation  the  patient 
occasionally  vomited,  Avas  Aveak  and  low- 
spirited,  and  there  was  a  considerable 
swelling  in  the  pelvis,  as  if  from  a  ha?ma- 
tocele  in  front  of  the  rectum,  to  siich  an 
extent  that  the  uterus  could  not  be  felt. 
Thei  e  were  frequent  A^ery  offensive  Avatery 
motions,  but  never  any  purulent  discharge. 
When  the  SAvelling  in  the  pelvis  began  to 
subside,  and  after  washing  out  the  rectum 
with  thymol  solution,  rapid  amendment 
set  in  a-^.d  Avent  on.     Two  days  before  she 


162 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


left  London  by  rail  for  Oxford,  on  April  8, 
just  a  month  after  operation,  I  carefully 
examined  the  pelvis  by  vagina  and  rectum, 
and  really  could  not  find  any  ti-ace  of  an 
operation  having  been  performed.  The 
uterus  was  in  its  normal  position,  was 
movable,  and  of  ordinary  size  and  weight. 
She  wrote  herself  in  May,  saying  '  I  am 
able  to  wallc  a  little,  and  get  out  in  the 
air  as  much  as  possible.'  But  improve- 
ment did  not  continue ;  a  pelvic  abscess 
formed,  which  was  not  opened,  and  she 
died  in  August. 

Mural  fibroid,  removed  ivith  the  r/)/Jit 
ovarij  and  Fallopian  tube ;  enucleation 
from  right  broad  lifiament,  a)idthin  capsule 
of  uterine  fhres;  death. — In  May  1882  Ire- 
moved  a  very  large  uterine  fibroma  from  a 
patient  of  Dr.  Grabham,  of  Madeira,  50 
years  of  age,  without  opening  the  uterine 
cavity,  only  cutting  away  a  thin  slice  of 
the  uterus  close  to  the  fundus,  Avith  the 
right  Fallopian  tube,  and  the  right  ovar}', 
which  was  attached  to  the  tumour.  The 
anterior  surface  of  the  tumour  was  first  ex- 
posed covered  by  broad  ligament,  which 
contained  many  very  large  veins.  On 
dividing  the  broad  ligament,  avoiding  the 
veins  as  much  as  possible,  white  fibroid 
structure  was  seen,  covered  by  a  very  thin 
layer  of  uterine  fibres,  forming  a  sort  of 
imperfect  capsule.  Cutting  away  the 
tumour  from  the  fundus,  and  applying 
forceps  to  the  bleeding  vessels,  the  uterus, 
after  the  tumour  w^as  cut  off,  appeared 
almost  normal  in  size,  shape,  and  consist- 
ence. Some  bleeding  vessels  on  the 
surface  of  the  divided  fundus  were  secured 
by  fine  ligatures.  Other  ligatures  were 
applied  to  vessels  in  the  divided  broad 
ligament.  The  edges  of  the  ligament 
were  afterwards  sewn  together  by  an  un- 
interrupted suture,  so  as  to  cover  the  cut 
surface  of  the  fundus.  The  left  tube  and 
ovary  were  not  disturbed.  The  patient 
died  4  days  after  the  operation,  with 
symptoms  of  obstructed  intestine.  No 
post-mortem  examination  could  be  made. 

r..\I'I.Ol:.\TOKY    INCISIONS 

In  addition  to  the  cases  Avhich  I  have 
related,  where  the  whole  of  a  tumour  has 
not  been  removed,  or  where  an  outgrowth 
has  been  removed  and  an  interstitial 
growth  not  interfered  with,  I  have  met 
with  cases  wliero  fibro-cystic  tumours 
have  been  punctured,  the  cyst  emptied, 
and  nothing  more  done.     In  one  case,  a 


uterine  cyst  was  drained  successfully,  the 
patient  dying  5  years  afterwards  of  kidney 
disease.  In  another  similar  case,  a 
uterine  cyst  was  successfully  drained,  but 
the  patient  died  4  years  afterwards  of 
malignant  disease.  In  1881,  I  emptied  a 
very  large  uterine  cyst  of  blood-clot  in  a 
patient  of  Dr.  Burd,  of  Shrewsbury,  and 
drained  it.  The  patient  recovered  and  is 
still  in  good  health. 

In  another  case,  a  patient  of  Dr. 
Andrews,  of  Hampstead,  a  single  lady, 
aged  GO,  I  was  only  able  to  remove  part 
of  a  fibroma,  after  emptying  a  large  cyst- 
like  cavity.  The  patient  died  on  the  ord 
day.  In  a  patient  of  Dr.  Monro,  of  New- 
town, Montgomeryshire,  where  I  could 
only  remove  a  projecting  outgrowth  from 
the  main  part  of  the  tumour,  the  patient, 
who  Avas  in  an  extremely  feeble  condition 
before  the  operation,  died  on  the  8th  day; 
and  in  February  188a,  in  a  lady  from 
Newfoundland,  I  made  an  unsuccessful 
attempt  to  enucleate  a  fibroma  which  in- 
volved the  left  side  of  the  fundus  and 
body  of  the  uterus,  and  was  covered  by 
the  left  broad  ligament.  I  only  removed 
a  small  part  of  a  very  large  tumour,  but 
the  patient  died  on  the  5th  day  of  septic- 
aemia. I  did  not  use  the  spray  in  this 
case,  but  adopted  all  other  usual  anti- 
septic precautions. 

In  a  table  of  31  cases  of  exploratory 
incision  and  partial  removal  of  uterine 
tumours,  published  in  1882,  in  my  book 
on  '  Uterine  and  Ovarian  Tumours,'  in 
IG  cases  nothing  more  was  done  than 
incision  of  the  abdominal  wall  and  re- 
moval of  peritoneal  fluid.  In  3  cases 
solid  tumours  Avere  simply  punctured. 
In  1  a  uterine  vein  was  Avounded.  In  1 
the  bladder  Avas  Avounded,  but  with  only 
temporary  inconvenience  to  the  jiatient. 
In  1  case  a  nodular  outgroAvth  Avas  re- 
moved, the  greater  part  of  the  groAvth  not 
being  disturbed.  In  this  case  the  patient 
Avas  much  more  benefited  by  the  operation 
than  could  have  been  reasonably  expected. 
In  the  cases  Avhcre  an  incision  only  Avas 
made,  no  harm  seems  to  have  been  done, 
and  Avhen  peritoneal  fluid  Avas  removed 
the  patients  were  neither  better  nor  Avorse 
than  after  a  simple  tapping.  I  think  it 
very  probable?  that  if,  Avith  my  present 
knoAvledge  and  experience,  I  had  to  treat 
similar  cases  now,  I  should  do  more  than 
I  did  then.  Tiie  progress  of  the  opera- 
tion has  been  that  of  gradual  development 
during  the  last  25  years,  and  there  can  be 


UTERINE   TUMOURS 


163 


iio  doubt,  as  experience  increases  and  the 
published  records  of  cases  carefully  ob- 
served and  truthfully  recorded  increase  in 
number,  that  quite  as  certain  rules  for 
our  guidance  "will  be  established  as  for 
any  other  great  surgical  operation.  As 
in  the  history  of  ovariotomy,  so  in  tliatof 
myomotomy,  there  have  been  periods 
when  the  general  principles  of  intra- peri- 
toneal and  extra-peritoneal  treatment 
have  by  turns  fallen  into  discredit,  and  of 
late  we  have  been  coming  to  a  sort  of 
understanding  that  when  the  tumour  can 
be  removed  without  opening  the  uterine 
cavity,  intra-peritoneal  treatment  is  pre- 
ferable ;  and  that  the  extra-peritoneal 
treatment  gives  better  results  whenever 
the  uterine  cavity  is  opened.  Still  more 
recent  experience,  especially  that  of 
Schroeder  and  Olshausen,  since  the  elastic 
ligature  has  been  frequently  iised,  appears 
to  favour  the  belief  that  as  in  ovariotomy, 
so  in  myomotomy,  intra-peritoneal  treat- 
ment will  be  the  rule,  extra-peritoneal 
the  exception.  Here  again  I  Avould 
repeat  that  this  question  can  only  be 
settled  by  careful  observation,  larger  ex- 
perience, and  truthful  record. 

SUBMUCOUS    INGROWTHS 

towards  or  into  the  uterine  cavity  are 
quite  as  common  as  subserous  outgrowths 
into  the  peritoneal  cavity,  or  as  intra- 
mural growths.  It  is  not  uncommon  to 
see  all  3  varieties  in  the  same  uterus,  but 
occasionally  the  ingrowth  is  the  only  form 
of  the  disease.  It,  is  more  commonly 
attended  with  serious  haemorrhage  than 
either  of  the  other  forms,  and  the  hgemor- 
rhage  is  generally  the  symptom  which 
leads  to  the  examination  and  the  discovery 
of  the  tumour.  Sometimes  the  os  is  more 
or  less  dilated,  and  if  the  growth  is  pedi- 
cled,  it  may  be  pulled  by  a  hook,  or 
corkscrew,  through  the  os  into  the  vagina. 
When. the  os  is  not  dilated,  a  sound  may 
sometimes  be  passed  more  or  less  com- 
pletely round  the  growth,  showing  that 
we  have  to  do  with  an  intra-uterine 
polypus.  In  other  cases  the  cavity  is 
more  or  less  blocked  up  by  a  mural 
growth  surrounding  it,  or  projecting  into 
it,  from  one  side,  or  developed  in  the 
«ervix,  one  or  other  lip  of  Avhich  may 
project  downwards  into  the  vagina. 

Where  fibroid  ingrowths,  or  polypi, 
have  a  distinct  pedicle,  the  old  plan  of 
tying  the  pedicle  and  allowing  the  polvpus 


to  slough  away  is  now  completely  aban- 
doned. Where  the  pedicle  is  hard,  and 
not  very  large,  it  may  be  divided  by  the 
scissors,  or  polyptome,  Avith  very  little 
risk  of  bleeduig,  and  the  polypus  removed 
by  forceps,  hook,  or  corkscrew.  In  the 
larger  and  softer  pedicles  I  know  of 
nothing  which  answers  so  Avell  as  crush- 
ing with  an  ordinary  lithotrite,  or  with 
Aveling's  polyptrite,  cutting  away  the 
polypus,  and  leaving  the  lithotrite  tightly 
screwed  on  for  a  few  minutes  afterwards. 
I  have  occasionally  put  on  1  or  2  pairs  of 
pressure-forceps  to  a  pedicle,  either  before 
cutting  away  the  polypus,  or  when  bleed- 
ing occurred  after  cutting  away,  and  have 
left  the  forceps  hanging  out  of  the  vagina 
ibr  several  hours ;  and  1  prefer  this 
method  to  the  more  conmion  one  of 
applying  perchloride  of  iron  and  plugging 
the  vagina. 

Where  ingrowths  projecting  into  the 
uterine  cavity  are  covered  by  the  mucous 
membrane,  but  have  no  pedicle,  and  have 
been  exposed  after  dilatation  of  the 
cervix ;  or  when  they  occupy  one  lip  of  the 
cervix,  Avhich  is  thus  enlarged  and  pro- 
jects into  the  vagina,  the  mucous  mem- 
brane over  the  projecting  portion  may  be 
divided,  either  with  the  knife  or  with 
Paquelin's  cautery,  and  ergot  may  be 
given.  Occasionally  in  this  way  a  sort  of 
spontaneous  expulsion  of  the  growth  is 
obtained.  Sometimes  the  effect  of  the 
uterine  contractions  may  be  assisted  by 
drawing  the  growth  down  by  forceps,  or 
hook,  while  by  the  finger,  or  some  blunt 
instrument,  the  growth  is  separated  from 
the  uterine  tissue  in  which  it  has  been 
imbedded.  In  this  way  I  have  removed 
very  large  solid  uterine  ingrowths.  In 
one  case  the  growth  Avas  so  large  that 
after  I  had  separated  it.  Dr.  West  put  on 
an  ordinary  pair  of  midwifery  forceps, 
and  in  removing  the  growth  the  perineum 
Avas  ruptured  completely  through.  I 
applied  4  sutures  immediately,  and  union 
Avas'  so  perfect  that  the  patient  knew 
nothing  of  the  injury.  I  have  twice  had 
to  cut  up  these  growths  into  several  pieces 
before  they  could  be  removed  from  the 
vagina,  and  I  have  several  times  had 
difficulty,  after  separatmg  an  intra-uterine 
fibroid  from  its  attachments,  in  getting  it 
through  the  os.  Once  Avith  Dr.  Lips- 
combe,  Of  Tring,  Avho  had  fully  dilated 
the  cervix  by  tents  before  my  arrival,  I 
had  succeeded  in  separating  the  uterine 
attachments  of  an  intra-uterine  growth  as 


1G4 


UTERINE   AND   OTHER   ABDOMIXAL   TUMOURS 


large  as  nn  infant's  head,  but  could  not  get 
it  through  the  os,  which  appeared  to  have 
been  stimulated  to  contraction  by  my  mani- 
pulation. Fearing  to  keep  up  the  action 
of  chloroform  very  long,  -\ve  allowed  the 
patient  a  few  hours'  sleep,  and  next 
morning,  under  a  very  deep  anaesthesia,  I 
cut  the  tumour  into  several  pieces  with 
strong  scissors,  and  thus  removed  the  whole. 
Recovery  Avas  most  satisfactory,  but  I 
know  of  nothing  that  is  more  trying  to 
the  patience  of  a  surgeon,  or  more  fiitigu- 
ing,  than  the  performance  of  one  of  these 
operations.    In  1884  I  removed  m.ore  than 

00  pounds  of  a  solid  fibroid  mass  in  this 
Avay,  from  a  Spanish  lady,  a  patient  of 
Dr.  Leeson,  of  Dorset  Square.  She  Avas  in 
the  very  lowest  state  of  prostration  from 
loss  of  blood  before  the  operation,  and 
the  proceeding  occupied  fully  2  hours. 
In  this  case  the  result  was  fatal, 
but  I  feel  certain  that  in  this  way  there 
was  a  better  prospect  of  saving  life  than 
there  would  have  been  by  abdominal 
section.  In  May  1884,  with  Dr.  Walker, 
of  Maida  Vale,  I  removed  one  of  these 
ingrowths  almost  as  large  as  the  last- 
mentioned,  in  a  similar  manner,  after  a 
great  part  of  it  had  become  gan- 
grenous. The  gangrenous  portion  was  re- 
moved one  day,  antiseptic  injections  used, 
and  the  remainder  of  the  growth  was 
withdrawn  a  few  days  afterwards.  This 
patient  is  now  in  excellent  health,  and  I 
attribute  her  recovery  in  a  great  measure 
to  Dr.  Walker's  assiduous  care  in  keeping 
up  constant  irrigation  of  the  vagina  and 
uterine  cavity  Avith  a  solution  of  per- 
chloride  of  mercury — 1  in  2,000 — which, 
after  many  others  had  been  tried,  was 
found  to  be  the  only  di.sinfectant  that 
freed  the  room,  or  even  the  house,  from 
the  almost  insufferable  odour. 

Professor  Olshausen  says  that  he  has 
performed  myomotomy  in  3G  cases,  of 
whom  12  died.  Nine  of  these  cases  were 
pedunculated,  of  Avhich  8  recovered,  and 

1  died.  There  were  8  cases  in  Avhich, 
although  there  was  no  pedicle,  the  uterine 
cavity  was  not  opened  ;  of  these  4  re- 
covered and  4  died.  Out  of  17  cases 
Avhere  the  uterine  cavity  Avas  opened, 
10  recovered  and  7  died.  Two  retro- 
peritoneal cases,  enucleated,  both  rocoA'ered. 
Jn  8  cases  the  pedicle  or  the  cervix  uteri 
Avas  secured  by  elastic  ligature,  which 
was  left  in.  In  1.')  cases  the  broad 
ligament  av;is  also  .secured  Avith  elastic 
lijjatiu'es.     Jn   2  cases  the  tiunour.s  were 


fibro-cystic  ;  in  all  the  other  cases,  .solid. 
SeA^eral  tumours  Avere  very  large:  18, 
20,  28,  44,  and  one  50  pounds.  The 
cause  of  death  in  1  case  was  urcemia, 
1  ureter  having  been  tied  ;  in  1,  obstructed 
intestine;  in  4,  shock;  in  1,  pulmonary 
embolism ;  in  5,  peritonitis  and  septicemia. 

To  sum  up  shortly  the  result  of  my 
OAvn  operative  Avork  in  cases  of  uterine 
tumours  from  I860,  when  the  operations 
Avere,  Avith  fcAv  exceptions,  undertaken 
unexpectedly  in  place  of  the  ovariotomy 
prepared  for,  or  in  cases  of  diagnosi;^ 
confessedly  doubtful  before  operation, 
down  to  the  later  years  when  an  accurate 
diagnosis  has  been  made  in  almost  every 
case,  it  appears  that  50  uterine  tumours 
have  been  removed  Avith  the  result  of  27 
recoveries  and  24  deaths. 

Of  the  outgrowths,  20  recovered,  17 
died.  Where  the  uterine  cavity  AA'a.s 
opened,  G  recovered,  3  died.  Cases 
treated  extra-peritoneally,  10  recovered, 
10  died.  Cases  treated  intra- peritoneally, 
16  recovered,  10  died.  3  cases  wherc- 
the  tumour  was  enucleated  died.  The 
notes  of  1  case  are  missing,  but  I 
believe  it  Avas  a  fibroid  Avith  a  large  base, 
and  one  ovaiy  Avas  removed  at  the  same 
time.     The  Avoman  died  of  peritonitis. 

The  largest  tumour  Avas  retro-peri- 
toneal, and  Aveighed  70  pounds — the 
patient  recovering. 

COMPLICATION    OF    UTERINE    TUMOURS    WITH 
rREGNANCY 

It  is  not  an  iinfrequent  subject  of  con- 
sultation, Avhen  an  unmarried  patient  or  a 
Avidow  has  a  uterine  tumour,  Avhether  or 
not  she  should  marry.  Of  course  the 
question  is  much  simplified  if  the  patient; 
has  passed  the  child-bearing  age.  Wlien 
under  that  age  two  questions  arise.  The 
pelvis  may  he  so  blocked  by  the  lower 
segment  of  the  tumour  as  to  be  an  impe- 
diment to  marital  intercourse.  When  thi.s 
is  not  the  case,  two  further  questions  arise : 
the  1st,  is  pregnancy  probable  ?  2ndly,  if 
it  occur,  Avould  it  be  dangerous  to  the 
mother,  or  the  l)irth  of  a  living  child  be 
improbable?  All  these  questions  have 
frequently  come  before  me  in  consulta- 
tion. I  have  known  a  case  Avhero  an  in- 
tending husband  Avas  not  stopped  by  the 
a.ssurance  that  not  even  a  catheter  could 
be  passed  into  the  vagina;  just  as,  in 
another  case,  a  young  couple  insisted  on 
marrvii^.g,  although  Dr.  Farre  and  I  gave 


UTERINE   TUMOURS 


1G5 


a.  written  certificate  that  tlie  case  was  one 
<i£  congenital  absence  of  the  uterus,  and 
])robably  of  both  ovaries.  On  the  other 
hand,  I  have  known  engagements  broken 
off  as  soon  as  one  of  the  parties  was 
informed  that  a  uterine  tumour  existed. 
Ill  one  case,  which  I  attended  with  Dr. 
Farre,  a  widower  was  informed  by  us  that 
tlie  young  lady  he  proposed  to  marry 
had  a  large  uterine  tumour,  Avhich  partly 
blocked  up  the  pelvis.  As  he  persevered 
in  his  desire  to  marry,  she  was  placed 
very  fully  under  tlie  influence  of  chlo- 
rof"orm,  and  while  tlie  hips  were  raised, 
J)r.  Farre  succeeded,  after  very  great 
difficulty,  in  pushing  up  the  lower  part 
of  the  tumour  above  the  brim  of  the 
pelvis.  She  married  soon  afterwards, 
and  Dr.  Playfair  attended  her  exactly  9 
months  later,  delivering  her  of  a  living 
child  without  much  difficulty.  Consider- 
able diminution  in  the  size  of  the  tumour 
followed  delivery  ;  the  lady  went  to  China, 
and  I  have  heard  that  there  has  certainly 
been  one  child,  and  I  believe  more,  since.  I 
have  known  other  cases  Avhere  pregnancy 
has  gone  on  to  the  full  term  in  patients 
suffering  iirom  uterine  tumours,  even  of 
considerable  size,  and  I  do  not  remember 
one  where  there  was  any  great  difficulty 
in  consequence,  nor  any  very  unusual 
ha3morrhage.  I  have  notes  of  2  cases 
where  tumours  of  considerable  size  dimi- 
nished very  rapidly  after  delivery,  almost 
disappearing  in  a  few  weeks — cases  so 
carefully  noted  by  myself  and  others, 
that  I  could  have  no  doubt  whatever  as 
to  the  fact. 

In  one  case  I  was  called  hurriedly  to  a 
lady  in  great  pain,  and  found  labour  so 
far  advanced  that  I  could  not  leave  her. 
I  sent  for  Dr.  West,  but  the  child  was 
boi'n  and  the  placenta  expelled  before 
he  arrived.  So  large  a  tumour  remained 
in  the  abdomen  that  we  thought  it  was  a 
twin,  but  it  proved  to  be  a  large  uterine 
tumour,  which  did  not  retard  the  con- 
valescence of  the  patient.  This  tumour 
Avas  very  much  smaller  a  few  months 
afterwards. 

The  question  as  to  whether  pregnancy 
is  likely  to  occur  must  be  answered  in 
reference  to  the  situation  of  the  tumour, 
and  whether  the  uterine  cavity  is  much 
altered  in  its  size  and  form.  But,  speak- 
ing generally,  without  much  statistical  in- 
formation by  Avhich  one  can  be  guided, 
and  doubting  whether  Simpson's  calcula- 
tion of  a  diminished  proportion  of  sterile 


to  fertile  women  fiom  1  in  10  to  1  in  8,  as 
a  consequence  of  the  presence  of  uterine 
tumours,  can   be   based  upon  a  sufficient 
number   of    cases,    my    own    experience 
would  certainly  lead  me  to   believe   that 
these    tumours    not    ordy    interfere    with 
conception,  but  frequently  lead  to  abor- 
tion— and  that  when  pregnancy  goes  on, 
delivery  Avill   not  be   free   from   unusual 
dangers.     The   surgeon   may   be   content 
with  giving  this  information,   and    leave 
those  who  are  interested  in  the  question  to 
act  according  to  their  own  judgment. 

The  histoiy  of  one  patient  whom  I  saw 
in  1862,  in  consultation  with  Dr.  Madge, 
illustrates  the  difficulty  which  may  arise 
when  fibroid  tumours  low  down  in  the 
pelvis  impede  delivery.  The  particulars 
were  laid  before  the  Obstetrical  Society 
by  Dr.  Madge,  and  I  quote  portions  of  his 
report. 

'Mrs.  II.,  ajt.  27,  primipara,  well- 
grown,  in  robust  health,  and  who  had 
gone  her  fall  time,  was  taken  with  slight 
labour  pains  on  the  morning  of  May  28. 
On  making  an  examination  in  the  after 
part  of  the  day,  I  found  the  pelvis  occu- 
pied by  a  large  round  tumour,  Avhich 
at  first  appeared  to  me  to  be  the  child's 
head.  It  seemed,  however,  to  be  lifting 
up,  as  it  were,  and  pushing  forwards  the 
posterior  wall  of  the  vagina.  It  was  low 
down,  and  came  lower,  but  receding  again, 
with  every  pain.  It  appeared  to  fill  up 
every  niche  in  the  pelvis,  so  that  the 
finger  could  not  be  passed  round  it.  The 
OS  uteri  could  not  be  felt.  Next  day  the 
tumour  was  occupying  precisely  the  same 
position.  The  pains  Avere  still  slight  and 
not  frequent,  and,  as  the  patient  Avas  in 
her  usual  health  and  spirits,  it  Avas  con- 
sidered advisable  to  Avait.  In  the  evening, 
Avith  considerable  difficulty,  by  hooking 
my  finger  high  up  behind  the  symphysis 
pubis,  I  Avas  enabled  to  reach  the  os  uteri ; 
it  Avas  directed  forwards,  dilated  to  about 
the  size  of  a  crown  piece,  and,  as  Avell  as 
I  could  make  out,  some  part  of  the  breech 
presented.  On  the  following  day  Dr. 
West,  Mr.  Spencer  Wells,  and  Mr.  NcAvton 
met  me  in  consultation.  Pains  getting 
more  frequent.  As  some  parts  of  the 
tumour  felt  soft  and  yielding,  a  trocar 
Avas  introduced,  and  a  small  portion  of 
fluid  draAvn  off.  Vain  attempts  had  been 
made  previously  to  push  the  tumour 
above  the  brim  of  the  pelvis.  Chloroform 
having  been  administered,  and  the  cathe- 
ter used,  the  opening  in  the  tumour  Avas 


166 


LTEKINE   AND   OTHER   ABDOMINAL   TUMOURS 


enlarged,     i\Ir.   Spencer  "Wells  was  then  ' 
enabled    to    push    the    tumour    upwards, 
and,    with  the  aid  of  a  blunt  hook,  tiie 
child  was  brought  down  by  the  buttock.  ! 
"When  born  it  had  some  iaint  signs  of  life,  ' 
but  could  not  be  made  to  breathe.     In 
the  early  part  of  the  following  day  the 
patient  seemed,  to  be  doing  Avell ;  as  the 
day    advanced,    by    fits    and    starts    she 
became  very  excited,  and  could  not  be 
persuaded  to  lie  still.     Peritonitis  set  in 
in  the  afteruoon,  and  she  died  on  the  oid 
day  after  confinement. 

'■  Autopsi/,  18  hours  after  death. — 
There  was  a  little  effused  lymph;  and 
underneath  the  viscera  about  a  pint  of 
bloody  serum.  The  tumour  Avas  lying 
above  and  in  a  line  with  the  uterus, 
nearly  reaching  by  its  upper  border  the 
epigastrium.  It  was  attached  to  the  pos- 
terior aspect  of  the  fundus  uteri  by  a 
long  pedicle,  and  had  thus  been  allowed 
to  drop  into  the  pelvis  at  or  before  the 
commencement  of  labour.  The  Aveight  of 
the  tumour  was  between  1  and  2  pounds, 
its  diameter  6j  inches,  and  it  consisted 
throughout  of  Avhite  fibrous  tissue.  Six 
small  tumours,  of  the  same  character, 
were  studded  about  the  external  surface 
of  the  uterus.' 

It  will  be  observed  that  in  this  case  a 
trocar  had  been  passed  through  the  vagina 
into  the  substance  of  the  timiour  before 
the  tumour  was  pushed  up.  In  a  case 
where  the  tumour  was  certainly  known  to 
be  solid  this,  of  course,  would  not  be  done. 
In  any  similar  case,  where  the  tumour  was 
detected  at  an  earlier  period  of  preg- 
nancy, either  so  low  in  the  pelvis  as  to 
be  an  impediment  to  delivery,  or  high  up 
in  the  abdomen,  the  question  Avhetlier 
pregnancy  should  be  allowed  to  go  on  to 
the  full  term,  or  Avhether  premature 
labour  should  be  brought  on,  or  the 
uterine  tumour  should  be  removed,  or 
the  prrgnant  organ  amputated,  must  be 
decided  by  the  conditions  in  each  case.  I 
haA'e  just  alluded  to  cases  Avhere,  with 
very  considerable  tuujcurs,  natural  deli- 
very, at  the  full  term,  of  a  living  child 
Avas  recorded.  But  other  cases  have  l)een 
related  by  Schroeder,  liegar,  and  Kalten- 
bach,  Avhere  in  the  early  months  of  preg- 
nanc3'  the  tumour  increased  with  such 
great  rapidity,  and  the  sufferings  of  the 
patients  became  so  distressing,  that  inter- 
ference Avas  necessary  in  order  to  save 
life.  The  induction  of  premature  labour 
under  such  conditions  has  proved  to  be 


so  dangei^ous,  and  the  emptying  of  the 
uterine  cavity  can  be  of  so  little  use,  that 
the  removal  of  the  tumour,  so  far  as  our 
present  knowledge  can  guide  us,  Avould 
seem  to  be  the  better  practice  ;  and  the 
fact  of  the  uterus  being  pregnant  does  not 
seem  to  have  added  much  to  the  difficul- 
ties and  dangers  of  the  operation  Avhen  it 
has  been  performed.  In  one  case,  Avhere  a 
myoma  about  double  the  size  of  a  child's 
head  between  the  uterus  and  the  liver, 
and  several  other  smaller  myumas,  Avere  re- 
moved firom  the  gravid  uterus  by  Schroe- 
der,  the  patient  Avent  on  to  the  end  of 
pregnancy,  and  had  a  liA'ing  child.  In 
another  case,  Avhere  he  amputated  a  uterus 
Avith  a  myoma  in  the  fundus,  about 
the  size  of  an  adult's  head,  Avith  several 
smaller  growths  as  large  as  an  apple,  or 
the  fist,  in  the  Avails  of  the  organ,  and  Avith 
a  3  months'  foetus  in  the  cavity,  the  patient 
recovered  Avithout  any  fever.  In  a  very 
similar  case,  performed  at  the  10th  week 
of  pregnancy,  the  patient  also  recovered, 
in  spite  of  a  seA'ere  bronchial  catarrh.  In 
Hegar's  case,  the  removal  of  the  tumour 
only  was  folloAved  by  the  death  of  the 
patient.  In  Kaltenbach's  case,  tumour, 
uterus  and  foetus  were  all  removed,  the 
stump  Avas  treated  extra-peritoneally,  and 
the  patient  recovered.  In  a  similar  case 
by  Wasseige,  treated  intra-peritoneally, 
the  patient  died.  Schroeder's  cases  Avere 
treated  intra-peritoneally. 

in  April,  1884,  Dr.  Bantock  operated 
on  a  lady  Avho  had  been  some  time  under 
notice,  and  Avhose  case  Avas  diagnosed  as 
one  of  multiple  uterine  fibroids.  He 
found  the  uterus  encumbered  Avith  2 
tumours,  1  large  cystic  tumour  from  the 
left  angle  of  the  fundus,  and  another,  more 
solid,  but  also  partially  cystic,  from  the 
right  angle  of  the  fundus.  The  uterus 
contained  a  foetus  of  3  months..  Supra- 
vaginal amputation  and  extra- peritoneal 
treatment  resulted  in  the  complete  re- 
covery of  the  patient,  Avho  at  the  end 
of  the  year  Avas  known  to  be  in  good 
health. 

Two  cases  illustrating  this  subject 
have  also  come  under  the  management 
of  my  colleague,  ]\Ir.  Thornton,  in  the 
Samaritan  Hospital.  The  first  patient 
Avas  a  married  Avoman,  39  years  of  age, 
in  an  advanced  stage  of  pregnancy.  In 
May,  1.S79,  he  removed  a  tumour,  attached 
by  a  pedicle  to  the  right  side  of  the 
uterus,  and  otherwise  slightly  adherent 
to  it,  and  not  only  Avedged  in  the  pelvis, 


UTERINE   TUMOUnS 


167 


complete     removal,    the     rule     is     that 
menstruation    is    stopped,    and    not  only 
excessive    loss    of    blood    at    the    men- 
Labour  came  on  about  9  hours  ,  strual    periods,    but    bleeding   from    the 
and  the  cliild  Avas  still-born  [  uterus  at  other  times,  supposing  there  to 

be  no  polypus,  is  also  stopped,  and  dimi- 
nution of  the  tumour  goes  on  more  or 
less  rapidly.  In  Jul}'',  iSS'j,  I  operated 
upon  a  patient  of  Dr.  Macintosh,  of 
Brompton,  who  had  a  A'ery  large,  solid 
uterine  tumour,  and  was  extremely  en- 


but    lirmly  fixed   to   the    brim    and    the 
■whole    of  the   pouch    of  Douglas.     The 
pedicle  was  first  clamped,  then  tied,  and 
returned, 
afterward 

without  any  difliciilty.     The  woman  sur- 
vived till  the  5  th  day. 

The  second  ojieration  was  in  July, 
18ft2.  Patient  married,  o8  years  of  age, 
had  carried  a  large  tumour  for  7  years, 
and  was  very  ill,  with  no  chance  of  going 


on  to  the  full  term.     Extensive  adhesions  j  feebled  and  pallid  from  repeated  hamor- 


had  to  be  separated.  An  elastic  ligature 
was  passed  round  the  cervix,  and  large 
forceps  were  placed  on  each  broad  liga- 
ment. The  uterus,  aj^pendages,  and  tu- 
mour Avere  all  cut  away,  the  elastic  liga- 
ture was  replaced  by  Kaberle's  serre-nceud 
and  the  stump  fastened  in  the  lower  corner 
of  the  wound.  The  patient  made  an 
excellent  recovery,  was  up  on  the  ISth 
day,  left  the  hospital  about  the  middle  of 
August,  remained  under  care  for  another 
fortnight,  aud  then  went  into  the  country. 
She,  however,  died  about  3  weeks  after 
her  return  home,  with  obscure  symjDtoms 
of  renal  or  intestinal  obstruction. 


EEMOVAL    OF    THE    OVARIES    IN    CASES    OF 
UTERINE    TU.AIOUKS 

The  alternative  proposal  of  removal  of 
the  ovaries  in  order  to  lead  to  premature 
cessation  of  menstruation  in  cases  of 
uterine  tumour  attended  Avith  much 
bleeding,  should  alwaj's  be  considered 
during  consultation,  Avhere  surgical  treat- 
ment is  called  for.  And  it  is  occasion- 
ally advisable  to  recommend  that  an 
operation  should  be  begun  with  the 
understanding  that  if  the  tumour  can 
only  be  removed  with  great  difficulty  and 
danger,  it  should  be  left  alone,  and  the 
ovaries  removed.  Whereas  if  the  tumour 
can  be  removed  Avithout  any  unusual 
hazard,  Avith  or  Avithout  one  or  both 
OA'aries,  it  should  be  taken  away.  In  one 
of  the  cases  Avhich  I  have  just  related, 
finding  that  there  Avould  be  unusual 
difficulty,  I  intended  to  remove  the  ova- 
ries, but  there  Avas  so  much  bleeding 
after  removing  one  and  such  difficulty 
in  stopping  the  bleeding,  that  I  removed 
the  tumour.  Sometimes  the  ovaries  are 
so  situated  in  these  cases  that  they  can  be 
easily  remoA^ed  ;  in  others  they  are  so 
confounded  Avith  the  tumour  that  it  is 
difficult  even  to  find  them.     After  their 


rhage.  I  took  away  both  ovaries  Avith  a 
most  satisfactory  result;  ha3morrhage  never 
reappeared  after  the  operation,  and  a  con- 
siderable diminution  in  the  size  of  the 
tumour  has  been  observed.  Dr.  Mackin- 
tosh saAv  his  patient  in  the  summer  of 
1 884  in  excellent  health,  there  having  been 
no  return  of  menstruation,  and  scarcely  any 
abdominal  tumour  to  be  felt.  In  a  similar 
case,  but  smaller  tumour,  in  a  young  lady, 
a  patient  of  Dr.  Priestley,  Ave  decided,  after 
consultation,  upon  the  alternative  extir- 
pation of  the  enlai-ged  uterus,  or  of  removal 
of  the  ovaries.  After  making  an  ex- 
ploratory incision,  removal  of  the  ovaries 
appeared  to  present  the  fcAver  difficulties, 
and  to  offi^r  the  best  chance  of  safety  to 
the  patient.  This  AA^as  done,  and  the 
result  has  been  most  satisfactory.  The 
operation  Avas  performed  in  1 88 1.  I  saAV 
the  patient  in  the  summer  of  ISHi  in 
excellent  health,  and  I  could  scarcely 
find  a  trace  of  the  tumour,  Avhich,  at  the 
time  of  operation,  had  extended  some 
inches  aboA^e  the  umbilicus. 

We  must  have  further  experience,  and 
a  larger  number  of  cases  carefully  re- 
corded, befoi'e  Ave  can  arrive  at  a  fair 
estimate  of  the  relative  value  and  danger 
of  the  two  courses  of  action  in  cases  of  this 
kind.  The  question  Avhether  the  o\'aries 
only,  or  the  ovaries  and  Fallopian  tubes 
should  be  removed,  must  be  decided  by 
the  condition  of  the  tubes.  If  healthy,  it 
Avould  be  absurd  to  remove  them ;  but  if 
diseased  they  should  with  equal  certainty 
be  taken  aAvay,  Avhether  free  or  adherent. 
It  is  very  important  that  every  frag- 
ment of  both  ovaries  should  be  completely 
cleared  aAvay.  If  adherent,  and  one  or 
both  are  twisted  or  scraped  aAvay  from 
their  connections,  if  only  some  very  small 
portion  be  left,  menstruation  may  after- 
Avards  occur  quite  regularly,  and  the 
operation  prove  more  or  less  a  failure, 
even  though  both  Fallopian  tubes  may 
have  been  totally  removed. 


1G8 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


It  is  to  be  hoped  that,  in  recording 
cases,  surgeons  will  be  as  careful  as 
possible  in  giving  the  dimensions  of  the 
tumour  before  the  ovaries  were  removed, 
and  the  dimensions  at  certain  definite 
periods  afterwards.  In  September  1884, 
Ur.  Harvey  brought  two  interesting  cases 
before  the  Calcutta  INIedical  Societ)',  in 
which  ho  had  renioved  both  ovaries,  which 
were  quite  licahhy,  on  account  of  uterine 
tumour?.  One  of  these  tumours  was  ac- 
companied by  excessive  menorrhngia,  the 
other  by  dypmenorrhoia  and  interference 
Avith  action  of  bladder  and  bowels.  In  tlie 
first  case  the  tiimoxu*  was  about  5  inches 
across  between  the  Fallopian  tubes.  The 
tumour  '  practically  disappeared  within  G 
months.'  In  the  .second  case  the  uterus 
at  the  time  of  operation  Avas  as  large  as  at 
the  end  of  7  months'  pregnancy.  Within 
3  months  '  the  iiterine  tumour  had  shrunk 
to  half  its  former  size.'  Dr.  Harvey  does 
not  appear  to  have  touched  the  Fallopian 
tubes  in  either  of  these  cases.  In  a  third 
case,  where  tlie  uterus  reached  within  ^  an 
inch  of  the  umbilicus,  both  ovaries  were 
removed,  the  right  'with  difficulty  along 
with  the  thickened  tube.'  The  patient  died 
on  the  9th  day,  of  peritonitis  and  septic- 
aemia. Dr.  Harvey  adds,  '  The  objection 
to  the  operation  that  it  unsexes  the  woman 
and  makes  it  impossible  for  her  to  have 
children,  is  sufficiently  met  by  the  fact 
that  in  the  cases  when  the  operation  is 
justifiable  the  woman  is  in  the  last  degree 
unlikely  to  conceive,  and  it  v/ould  be  very 
unfortunate  should  she  do  so.' 

In  August  188-^,  at  the  meeting  of 
the  International  Congress  at  Copenhagen, 
Dr.  Wiedow,  of  Freiburg,  showed  that  of 
149  cases  of  castration  for  uterine  growths, 
15  died — a  mortality  of  about  10  per  cent. 
Comparing  this  Avilli  the  much  larger 
mortality  of  myomotomy,  he  argues  that 
castration  must  be  the' better  practice  if 
the  results  are  proved  to  be  good;  and 
he  shows,  by  an  analysis  of  the  cases, 
that  the  results,  both  as  regards  stopping 
of  the  bleeding  and  shrinking  of  the 
tumours,  have  been  generally  satisfac- 
tory, and  that  removal  of  the  Fallopian 
tubes  has  little  or  no  influence  upon  the 
results.  He  insists  that  complete  removal 
of  both  ovaries  is  of  the  utmost  import- 
ance;  for,  when  any  portion  of  either 
ovary  has  been  left,  even  if  both  Fallo- 
pian tubes  have  been  removed,  menstrua- 
tion has  recurred  quite  unmodified  by  tlie 
operation. 


TUMOURS    OF    THE    FALLOPIAN    TUBES 

Another  class  of  abdominal  tumoura 
is  found  in  the  form  of  enlargement  of 
the  Fallopian  tubes.  Tumours  of  the 
Fallopian  tubes,  though  generally  taking 
the  form  of  distended  sacs,  are  not 
always  cyst-like.  They  are  sometimes 
solid.  When  the  contents  are  fluid,  they 
vary  as  to  their  nature.  We  may  range 
tumours  of  the  Fallopian  tubes  in  the 
following  order : 

1 .  Dilated     tubes     containing     clear 
fluid. 

2.  Dilated  tubes  with   pundent  con- 
tents. 

3.  Dilated  tubes  containing  blood  or 
menstrual  fluid. 

4.  Tubes  enlarged  by   papillomatous 
growths. 

5.  Tubes  enlai-ged  by  fibrous  deposit. 

6.  Tubes   including  the  products   of 
conception. 

Numbers  4,571  and  4,572  in  the  Museum 
of  the  College  of  Surgeons  are  specimens 
of  these  tumours,  formed  by  dilatation  of 
the  Fallopian  tubes,  Avhich  I  removed  in 
1877.  These  tubes  were  both  distended 
with  fluid.  The  patient,  single,  23  years 
of  age,  Avas  admitted  into  the  Samaritan 
Hospital  in  July  1877,  with  an  abdominal 
tumour,  which  extended  midway  betAveen 
the  umbilicus  and  ensiform  cartilage,  and 
under  the  left  false  ribs,  drawing  the 
bladder  upAvards,  and  pushing  the  uterus 
downwards.  Douglas's  pouch  Avas  filled 
by  a  solid  mass  which  moved  Avith  the 
abdominal  tumour.  The  catamenia  Avere 
regular.  The  tumour  had  only  been 
noticed  about  9  months  before,  but 
steadily  increased.  It  Avas  supposed  to 
be  a  nudtilocular  ovarian  cyst.  On  open- 
ing the  peritoneum,  2  tumours  separated 
by  a  deep  fin-row  Avere  seen.  That  to  the 
right  Avas  first  turned  out  Avithout  being 
opened.  A  ligature  Avas  applied  upon  a 
very  narrow  neck,  Avhich  proved  to  be 
the  closed  uterine  end  of  the  right  Fallo- 
pian tube.  This  Avas  divided  beyond  the 
ligature.  A  very  similar  dilatation  of 
the  left  Fallopian  tube  Avas  treated  in 
the  same  manner.  Both  Fallopian  tubes, 
closed  at  both  ends  and  dilated  into 
cj'st-like  tumoiu's,  Avere  removed  without 
being  tapped  or  opened.  The  right  ovary 
Avas  removed  Avith  the  right  tube.  The 
left  ovary  Avas  not  disturbed.  The  weight 
of  one  tumour  Avas  4  pounds  1 1  ounces, 


UTERINE   TUMOURS 


169 


of  the  other,  1  pound  G  ounces.  There 
was  nothing  in  the  fkiid  contained  in 
either  cyst  to  distinguish  it  from  ordinary 
ovarian  fluid.  The  woman  recovered 
well,  left  the  hospital  0  weeks  after  opera- 
tion, married  in  A\ni[  1878;  and  I  saw 
her  in  September  1S81,  in  good  health, 
the  catamenia  having  been  quite  as 
regular  as  before  oi)eration,  but  more 
■copious.  In  Mr.  Doran's  account  of  the 
preparations  in  the  Museum  of  the  College 
of  Surgeons,  he  says :  '  Several  pedun- 
culated cysts  sprang  from  tlie  broad 
Jigament.  Some  of  the  cysts  contained 
vegetations  similar  microscopically  to  the 
papillomatous  growth  from  the  interior 
of  the  Fallopian  tube  which  will  shortly 
be  described.'  Mr.  Doran  is  here  refer- 
ring to  the  following  vei-y  remarkable 
case. 

In  the  autimm  of  1877,  a  maiden 
lady,  a  patient  of  Mr.  Bickersteth,  of 
Liverpool,  began  a  long  illness  with  tume- 
faction of  the  abdomen  and  an  attack  of 
right  ovaritis.  She  was  tapped.  This  was 
followed,  in  the  spring  of  1878,  by  pleural 
effusion  on  the  right  side.  120  ounces 
of  clear  fluid  were  removed  by  tap- 
ping. Then  the  ascitic  fluid  re-collected 
at  the  end  of  2  or  3  months.  Tapping 
to  the  extent  of  24  ounces.  In  another 
3  months  the  right  pleura  again  required 
tapping,  100  ounces  of  fluid  being  re- 
moved. Three  months  more,  tie  abdo- 
men had  a  third  time  become  swollen, 
and  16  pints  were  drawn  off.  But 
throughout  the  period  of  these  alternating 
pleiiritic  and  peritoneal  effusions,  and 
ever  since  the  subsidence  of  the  original 
symptoms  of  pelvic  inflammation,  there 
had  been  neither  acute  disturbance  of  the 
system,  nor  even  a  rise  of  temperature; 
and  after  each  tapping  recovery  appeared 
for  a  time  to  t)e  complete.  No  signs  of 
heart  or  liver  disease.  The  last  tapping 
was  done  in  January,  and  in  INIarch, 
1879,  as  the  case  was  as  obscure  as  ever, 
the  patient  was  referred  to  me.  Mr. 
Bickerstcth  had  detected  a  dull  note  on 
percussion  in  the  flanks,  most  marked  on 
the  right  side.  The  abdomen  Avas  again 
full,  and  there  was  also  some  fluid  in  the 
thorax.  So  I  advised  an  exploratory 
incision.  This  Avas  objected  to,  and  the 
abdomen  was  simply  tapped.  The  fluid 
had  a  sp.  gr.  of  10 o2,  Avas  charged  Avith 
idbumen,  and  the  scanty  deposit  gave 
evidence  of  vacuolated  cells,  indicating 
some    proliferating     disease.      The    tap- 


ping, however,  enabled  me  to  detect  a 
hard,  nodular  mass  behind  the  uterus, 
Avhich  organ  Avas  freely  moA'able,  and  so 
low  in  the  pelvis  that  the  cervix  lay  close 
to  the  vulva.  An  operation  Avas  impera- 
tive, and  I  opened  the  peritoneum  in 
April  1879.  Seventeen  pints  of  opalescent 
fluid  escaped.  The  left  ovary  was  normal. 
To  the  right  of  the  uterus,  not  larger  than 
natural,  a  tumour  Avas  found  the  size  of 
an  orange,  and  consisting  of  the  greater 
part  of  the  right  Fallopian  tube,  Avith  the 
ovary  behind  it.  A  ligature  av;is  applied 
between  the  tumour  and  the  uterus,  and 
the  tumour  Avas  cut  away.  The  ovary 
Avas  also  removed  after  ligature.  No 
secondary  deposits  Avere  found  on  the 
peritoneum.  The  patient  made  a  rapid 
recovery. 

A  small,  thin-Avalled  cyst  projected  from 
the  surface  of  the  ovary,  Avhich  Avas  not 
otherwise  diseased.  Aboitt  an  inch  of  the 
innermost  portion  of  the  Fallopian  tube 
remained  itndilated  and  quite  pervious. 
The  other  part  formed  an  elongated 
tumour,  3^  inches  Iong,Avith  the  fimbriated 
extremity  quite  open,  and  the  fimbrise, 
although  thickened  and  shortened,  re- 
mained quite  distinct.  The  distended 
section  of  the  tube  Avas  filled  Avith  cauli- 
flower excrescences,  Avhich  grcAV  from  all 
parts  of  the  mucous  membrane.  Several 
cysts,  Avith  thin  Avails  and  smooth  exteriors, 
rose  by  narrow  pedicles  from  amidst  the 
excrescences,  and  contained  papillary  out- 
groAvths.  The  caulifloAver  groAVths  Avere 
covered  Avith  countless  secondary  off- 
shoots, and  on  the  free  surfaces  there  Avas 
a  single  layer  of  columnar  epithelium,  a 
feAV  of  the  cells  being  ciliated.  The  blood 
supply  was  scanty,  and  in  some  parts  of 
the  stroma  chondrification  had  taken 
place.  The  disease  had  begim  with  local 
inflammation,  causing  hyperplasia  of  the 
tubal  mucous  membrane,  developing  into 
the  Avarty  and  papillary  growths,  and 
accompanied  Avith  an  acrid  mucous  secre- 
tion. This  escaping  by  the  open  end  of 
the  tube,  caused  the  morbid  effusion  of 
the  peritoneum,  and  the  abundant  ascitic 
fluid.  The  cells  found  in  the  fluid  Avere 
epithelial,  the  growth  Avas  epithelial,  con- 
fined to  the  free  surfaces,  and  there  was 
nothing  in  it  of  a  cancerous  character. 

The  patient  had  another  attack  of 
pleurisy  in  the  foUoAving  autumn,  has 
ceased  to  menstruate,  and  in  1884  still 
lives  in  good  health,  Avithout  any  signs  ot 
the  reappearance  of  the  papillary  growth 


170 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


in  other  parts,  or  of  any  fresh  formation 
of  ascitic  or  pleural  fluid. 

This  is  the  only  case  of  papillomatous 
tumour  of  the  Fallopian  tube  that  I  have 
CA'er  removed,  and  the  case  previously 
related  is  the  only  one  in  which  I  have 
removed  tubes  dilated  into  cyst-like 
cavities  during  my  20  years'  practice  at 
the  Samaritan  Hospital.  I  saw  one  case 
in  consultation  in  1884,  which  Avas  after- 
wards operated  on  by  Mr.  Thornton,  and 
another  which  I  removed  myself  in  October, 
LS84.  The  tube  in  this  case  was  qi:ite 
closed  at  both  ends,  and  the  central  por- 
tion of  the  tube  was  dilated  into  a  thin- 
walled,  cylindrical,  cyst-like  body,  which 
liad  a  remarkable  resemblance  to  intestine. 
A  single  ligature  at  the  uterine  end  of 
the  tube  was  all  that  was  required  before 
cutting  away  the  tumour.  The  uterus, 
the  other  tube,  and  the  ovaries  appeared 
to  be  quite  normal.  The  cavity  contained 
about  2  pints  of  fluid,  closely  resemb- 
ling some  variety  of  ovarian  fluid.  It  also 
contained  a  great  deal  of  cholesterine. 
The  dilated  tulje  is  now  in  the  Museum 
of  the  College  of  Surgeons.  The  patient 
recovered  Avithout  any  fever,  menstruated 
ireely  from  the  4th  to  the  8th  day  after 
the  operation,  left  for  Yorkshire  on  the 
21st  day,  and  I  have  had  grateful  letters 
irom  her  since. 

Considering  how  very  frequently  I 
have  performed  the  operation  of  ovario- 
tomy, it  seems  remarkable  that  these  four 
cases  are  the  only  examples  I  have  met 
Avith  Avhere  either  one  or  both  Fallopian 
tubes  have  been  so  diseased  as  to  lead  to 
their  removal.  I  have  reported  many 
cases  Avhere,  in  connection  with  ovarian 
tumours,  a  Fallopian  tube  has  been  con- 
siderably elongated,  and  its  canal  closed. 
In  one  case  it  Avas  dilated  and  formed  a 
channel  of  communication  between  a 
bleeding  ovarian  cyst  and  the  uterine 
cavity  and  the  vagina;  but  I  have  never 
seen  anything  su])porting  the  opinion  that 
disease  of  the  Fallopian  tubes  occur.s  Avith 
anything  approaching  the  extraordinary 
frequency  Avith  Avhich  by  some  it  is 
alleged  to  occur.  AVhen  treating  the 
pedicle  as  formei-ly  by  the  clamp,  and 
recently  by  the  ligature,  I  have  been 
guided,  as  to  including  the  tube  or  not, 
simply  by  the  ease  Avith  which  one  or  the 
other  could  be  done.  When  the  Fallopian 
tube  is  closely  attached  to  the  cyst  I 
usually  include  it  in  the  clamp  or  ligature. 
But  if  the  pedicle  can  be  readily  secured 


withoiit  including  the  tube  I  leave  it.  I 
have  scarcely  ever  been  decided  in  this 
matter  by  observing  signs  of  disease  in 
the  tube  itself,  although  I  remember  oc- 
casionally, though  not  very  often,  having 
removed  it  because  it  appeared  unusually 
red  or  swollen,  elongated  or  tortuous. 

No  doubt  the  tube  occasionally  be- 
comes the  seat  of  gonorrheal  inflamma- 
tion ;  but,  whateA'er  may  be  the  experience 
of  others,  my  OAvn  observation  Avould  lead 
me  to  believe  that  these  and  other  cases 
of  so-called  salpingitis,  or  pyo-salpinx, 
usually  recover  under  ordinary  care  and 
rest,  Avithout  surgical  treatment.  It  would 
appear  to  me  as  rational  to  perform 
castration  in  every  case  of  gonorrheal 
orchitis,  as  to  remove  the  Fallopian  tubes 
simply  because  they  are  inflamed  or  the 
seat  of  suppuration. 

Those  who  Avish  to  knoAv  more  about 
the  diseases  of  the  Fallopian  tubes,  since 
the  time  of  their  discoverer — Fallopius, 
1550- — and  of  Haller,  Bartholine,  Ruysch, 
Morgagni,  Cruveilhier,  Avill  do  Avell  to 
consult  Hennig's  Avork  on  '  Diseases  of  the 
Fallopian  Tubes  and  Tubal  Pregnancy,' 
published  in  1876.  They  Avill  there  find 
a  great  deal  of  A'aluable  information  as 
to  congenital  and  other  defects,  dilata- 
tion, atresia,  adhesions,  abnormal  con- 
tents, catarrh,  inflammation,  and  neAV 
Ibrmations;  Avhile  the  chapter  on  tubal 
pregnancy  contains  a  very  complete 
bibliography,  and  some  historical  notices 
of  recorded  cases  from  KiOl  doAVUAvards. 
The  section  on  the  pathological  anatomy 
includes  notices  of  interstitial,  tubal,  tubo- 
ovarian,  and  tubo-abdominal  pregnancy. 
The  sections  on  diagnosis  and  treatment 
are  less  .satisfactory,  and  do  little  more 
than  confirm  the  conclusion  to  Avhich 
experience  here  has  been  leading,  that, 
Avhenever  the  diagnosis  of  tubal  preg- 
nancy can  be  made  out  Avith  tolerable 
certainty,  the  risk  of  rupture  as  preg- 
nancy advances,  and  of  death  from  internal 
haemorrhage,  is  so  great,  that  the  removal 
of  the  dilated  tube  by  abdominal  section 
is  the  safest  and  best  practice.  But  here 
again  my  OAvn  experience  is  very  small. 
With  the  exception  of  one  case,  recorded 
by  ]\Ir.  Cooke,  in  the  5th  volume  of  the 
'  Obstetrical  Transactions,'  where  an  intra- 
uterine and  an  extra-uterine  pregnancy 
Avent  on  together  to  the  full  term  ;  and  an- 
other case  recorded  by  Mr.  Doran,  where 
a  ruptured  tube  containing  an  ovum  Avas 
found  after  the   death  of  the  patient,  I 


UTERINE   TUMOURS 


171 


am  not  sure  that  I  have  ever  seen  any 
variety  of  extra- uterine  foitation,  either 
in  my  own  practice  or  in  consultation. 

The  last  work  on  tubal  pregnancy,  by 
Dr.  J.  Veit,  of  Berlin,  published  in  1H<S4, 
contains  interesting  observations  on  the 
connection  of  tuljal  pregnancy  with  hajma- 
tocele,  and  upon  the  diagnosis  and  treat- 
ment of  tubal  pregnancy.  The  general 
conclusion  he  comes  to  is,  that  in  uncom. 
plicated  tubal  pregnancy  the  sac  should 
be  extirpated ;  but  when  a  lia3matocele 
has  formed,  or  the  foetus  is  dead,  that  rest 
and  expectation  are  to  be  recommended. 
When  ru[)ture  into  the  peritoneal  cavity 
has  taken  place,  he  advises  compression  of 
the  aorta,  and  only  under  extreme  neces- 
sity, direct  stoppage  of  haemorrhage  by 
laparotomy.  IMy  own  feeling  would  be 
that,  in  any  case  of  hcemorrhage  from 
rupture,  although  compression  of  the  aorta 
might  be  useful  in  temporarily  stopping 
bleeding  while  the  necessary  preparations 
for  laparotomy  Avere  being  made,  this 
operation  had  better  be  resorted  to  as 
soon  as  possible. 

TUMOUKS    OF   THE    ROUND   LIGAMENT 

I  have  only  twice  seen  the  round  liga- 
ment, as  it  passes  along  the  inguinal 
canal,  so  enlarged  as  to  form  a  solid 
tumour  ;  and  by  a  curious  accident  both 
patients  came  to  me  in  the  same  year.  I 
never  saw  a  case  before  that  time,  and  I 
have  never  seen  one  since.  Both  were 
on  the  right  side,  and  both  had  led  to 
great  difFereiace  of  opinion  among  men  of 
large  experience,  the  majority  looking 
upon  them  as  malignant  tumours.  About 
the  first,  I  was  myself  very  doubtful ;  but 
I  felt  confident  that  it  could  be  removed 
without  difficulty ;  and  the  patient  was 
otherwise  so  healthy  that  I  would  not 
believe  it  possible  that  the  tumour  could 
be  malignant.     A  linear  incision  throuQ;h 


the  integuments  exposed  a  fibroid  tumour 
considerably  larger  than  an  orange,  which 
was  very  easily  removed,  and  proved  to 
be  the  round  ligament  enlarged  just  after 
it  passed  through  the  internal  ring.  It  is 
now  in  the  Museum  of  the  College  of 
Surgeons.  The  structure  precisely  re- 
sembled that  of  a  uterine  fibro-myoma. 
The  patient  rapidly  recovered,  and  is  still 
after  many  years  in  good  health. 

The  second  case  occurred  very  soon 
after  the  first,  and  I  was  able  to  give  a 
correct  diagnosis.  This  tumour  was 
rather  larger,  of  the  same  structure,  and 
is  also  in  the  College  Museum.  The 
patient  recovered  without  difficulty. 

Much  more  commonly  than  solid  tu- 
mours of  the  round  ligament,  cystic 
tumours  are  found  in  the  inguinal  canal 
of  women,  and  are  known  as  hydrocele  of 
the  round  ligament.  I  have  seen  them  of 
various  sizes,  from  that  of  a  walnut  up  to 
a  cyst  capable  of  holding  10  or  12  ounces 
of  fluid.  I  have  no  notes  of  these  cases, 
but  I  must  have  tapped  at  least  20,  and 
the  fluid  has  always  resembled  that  of 
hydrocele  in  the  male.  I  have  once 
known  the  fluid  collect  again.  In  that 
case  I  injected  iodine  -with  complete  suc- 
cess. In  all  the  others,  so  far  as  I  know, 
simple  tapping  was  followed  by  a  cure. 
Anatomically  the  cystlike  cavity  in  which 
this  fluid  forms  is  supposed  to  be  a  dila- 
tation of  the  tubular  process  of  perito- 
neum into  the  inguinal  canal,  which  in 
the  foetus  is  called  the  canal  of  ISTuck. 
These  cases  are  frequently  mistaken  for 
oblique  inguinal  hernia,  but  the  diagnosis 
is  easy.  There  may  be  impulse  on  cough- 
ing, but  the  tumour  is  not  altered  by  the 
position  of  the  patient,  and  it  cannot  be 
reduced ;  there  is  no  gurgling  on  pressure, 
and  the  percussion  note  is  dull.  When 
large,  fluctuation  is  perceptible,  and  in 
thin  Avomen  transparency  may  sometimes, 
be  made  evident. 


CHxiPTER   II 

ON   PARTIAL    AMPUTATION    AND    ON    COMPLETE    EXCISION    OF    THE    UTERUS 


The  removal  of  fibroid  tumours  of  the 
uterus  and  the  partial  amputation  of  the 
hypertrophied  uterus,  have  led  on  to  its 
more  or  less  complete  extirpation  in  cases 


of  uterine  cancer.  The  names  of  Blun- 
dell  and  Freund  are  associated  Avith  these 
operations.  More  recentl}''  Poi'ro  has 
supplemented   the    Ca^sarean    section  by 


UTERINE   AND   OTHER   ABDOxMINAL   TUMOURS 


the  removal  of  the  upper  part  of  the 
uterus  leaving  the  vaginal  portion  after 
amputation  at  abotit  the  division  between 
the  neck  and  the  body  of  the  organ.  The 
case  which  I  am  about  to  describe  is  not 
identical  with  any  of  these  proceedings. 
It  was  not  a  supra-vaginal  amputation, 
but  a  complete  taking  away  of  the  whole 
gravid  uterus  and  its  appendages.  Even 
if  I  had  followed  Porro's  example  it 
would  have  been  the  first  case  of  the  kind 
in  Great  Britain,  But  cutting  round  the 
neck  into  the  vagina  and  leaving  no 
stump  makes  the  I'ollowing  case  of  exci- 
sion of  a  gravid  cancerous  uterus  not 
only  the  first  excision  of  the  entire 
gravid  uterus  in  this  country,  but  an 
operation  xmicjue  in  its  mode  of  perform- 
ance, completeness,  and  success. 

Bischoff,  of  Basle,  in  1S79  removed  a 
uterus,  the  cancerous  cervix  of  which 
impeded  delivery,  from  a  patient  41  years 
of  age,  and  at  the  34th  week  of  preg- 
nane}'. She,  however,  died  11  hours 
after,  the  lelt  ureter  having  been  tied.  It 
thus  seems  that  my  own  case  at  present  is 
the  only  one  of  the  kind  followed  by 
recovery  and  a  temporary  restoration  to 
health. 

The  patient  was  a  farmer's  v?ife, 
37  years  of  age,  pregnant  G  months  Avith 
her  Gth  child,  and  suffering  from  epithe- 
lioma of  the  cervix  uteri.  IShe  was 
brought  to  me  for  consultation  at  my 
house  by  Dr.  Goldsworthy  Tucker,  of 
Farningham,  on  October  5,  1881.  She 
had  borne  a  child  IG  months  previously, 
had  nursed  it  ibr  3  months,  became  weak 
and  troubled  with  vaginal  discharge,  but 
again  became  pregnant,  and  aborted  at 
0  weeks,  towards  the  end  of  1880  ;  again 
menstruated  in  March,  April,  and  May 
1881.  The  exact  date  of  the  last  concep- 
tion is  doubtful,  but  the  calculation  must 
be  made  from  tlie  month  of  May.  At  her 
first  visit  to  me  she  was  quite  conscious 
of  the  movements  of  the  child,  ballotte- 
ment  was  distinct,  and  I  could  hear  the 
sounds  t)f  the  fuctal  lieart.  The  cervix 
uteri  was  long  and  enlarged,  the  os  admit- 
ting one  finger  easily  for  1  inch,  and 
the  cervical  canal  was  surrounded  by  a 
mass  of  epithelioma,  which  everted  the 
lips  of  the  OS  and  projected  downwards 
into  tlie  vagina.  Proposals  for  the  in- 
ducing of  premature  labour  and  for  the 
removal  of  the  diseased  cervix  had  already 
been  discussed  in  previous  consultations 
■with  Dr.  Playfair ;    but   it  seemed   to  me 


that  the  disease  was  so  distinctly  limited 
to  the  cervix  that  if  all  the  morbid  tissue 
were  scraped  away  and  chloride  of  zinc 
applied  to  the  denuded  surface,  preg- 
nancy might  go  on  to  the  full  term. 
And  this  procedure  was  decided  upon. 
A  few  days  more,  however,  reduced  the 
patient  to  such  a  state  of  pain  and  weak- 
ness, with  great  increase  of  the  discharge, 
that  we  were  called  to  review  with  Dr. 
Graily  Hewitt  the  various  objections  and 
advantages  of  the  different  courses  open 
to  us.  Our  deliberations  ended  in  the 
decision  that  it  would  be  better  to  re- 
move the  Avhole  uterus  and  its  contents, 
and  I  accordingly  performed  the  opera- 
tion on  October  21,  with  the  assistance 
of  Mr.  Thornton  and  Mr.  Doran ;  Dr. 
Graily  Hewitt,  Dr.  Tucker,  and  Mr. 
Cadge  of  Norwich  being  present. 

The  patient  was  secured  as  for  ova- 
riotomy ;  bvit,  as  it  was  necessary  to  keep 
a  catheter  in  the  bladder,  an  opening  was 
made  expressly  for  it  in  the  waterproof 
covering.  The  vagina  was  plugged  with 
thymol  cotton,  wetted  with  warm  water 
containing  about  1  per  cent,  of  phenol.  I 
divided  the  abdominal  wall  in  the  middle 
line  to  an  extent  of  about  8  inches,  from 
2  inches  above  to  G  inches  below  the 
umbilicus.  The  uterus  thus  exposed  was 
about  the  size  of  a  large  adult  head. 
After  turning  it  out  I  inserted  4  sutures 
in  the  upper  part  of  the  wound  over  a 
large  iJat  sponge,  so  as  to  keep  back  the 
intestines  and  protect  the  abdomen  from 
needless  cooling  by  the  spray.  I  found 
the  ovaries  at  a  higher  level  and  nearer 
to  the  fundus  than  was  expected,  and  it 
was  cpiite  easy  to  secure  the  spermatic 
artery,  first  on  the  left  and  then  on  the 
right  side,  by  transfixing  the  broad  liga- 
ment below  each  ovary  and  tying  with 
strong  silk.  I  took  the  catheter  as  my 
guide  in  dissecting  the  bladder  from  the 
anterior  surface  of  the  uterus.  The  ex- 
panded uterine  coats  were  very  thin,  like 
a  tense  cyst,  and  they  were  soon  acci- 
dentally ruptured.  I  punctured  the  pro- 
truding membranes  and  a  quantity  of 
liquor  amnii  escaped.  The  next  thing 
was  to  draw  out  the  foetus,  and  tie  and 
cut  the  cord ;  but  I  did  not  interfere  with 
the  placenta.  I  then  separated  the  attach- 
ments between  uterus  and  vagina,  com- 
pletely circumcising  the  neck,  and  securing 
by  pressure-forceps  all  bleeding  vessels 
as  they  were  divided.  The  entire  uterus, 
with  all  the  diseased  parts  about  the  os 


PARTIAL  AND   COMPLETE   EXCISION   OF  UTERUS 


and  cervix,  was  thus  removed.  The  for- 
ceps were  then  taken  off  successively,  and 
every  bleeding  vessel  tied  with  carbolised 
silk.  Then,  taking  out  the  vaginal  pings, 
I  brought  together  the  opening  into  the 
vagina,  and  the  edges  of  the  divided  broad 
ligaments,  with  silk  sutures.  The  pelvis 
was  carefully  cleansed,  the  wound  closed 
as  usual  with  silk  sutures,  and  the  ordinary 
dressing  applied  as  after  ovariotomy. 

The  patient  was  under  the  influence 
of  methylene  for  about  75  minutes,  but 
the  operation  from  beginning  the  incision 
to  closing  the  wound  was  completed 
within  an  hour. 

Mr.  Cadge  kindly  noted  the  time 
occupied  by  the  different  stages  of  the 
operation  as  follows : 

2.35  r.M.  Patient  began  to  inhale  me- 
thylene. 


2.11  ]'.M.  Cathefrr    and    I'higging   va- 
gina. 
Incision  in  abdominal  wall. 
Uterus  drawn  out. 
Sutures    in     upper    part     (<f 
abdominal   wall,  dividing 
broad  ligaments  and  va- 
gina, removing  fcetus  and 
securing  vessels,  till 
Uterus  removed. 
Ligature  of  vessels  and  su- 
tures of  vagina  and  broad' 
ligaments. 
Closing  of  wound  and  dress- 
ing. _ 

0.55   ,,    Patient  in  bed. 
Tlie  uterus  has  been  preserved  in  the 
Museum  of  the  Royal  College  of  Sui-geons, 
and  the  accompanying   drawings  are  back 
and  front  views  of  the  preparation. 


2.50 
2.5)5 
2.5G 


r.io 

oAO 


3.50 


Tlie  first  of  these  drawings  shows  tlie 
posterior  aspect  of  the  entire  uterus  and 
ovaries  as  they  were  removed.  The  shi'ed 
of  peritoneum  seen  hanging  near  the  cen- 
tral part  ot  the  diseased  cervix  was  stripped 
from  the  anterior  surface  of  the  rectum. 

The  second  drawing  is  a  view  of  the 
anterior  siu-face,  showing  where  the  peri- 
toneal covering  of  the  uterus  was  divided, 
just  where  it  is  reflected  on  to  the  bladder. 


Just  below  the  line  of  divided  peritoneunx 
a  darker  line  shows  the  opening  into  the 
uterine  cavity  through  which  the  foetus 
was  drawn  out.  Btdow,  in  both  drawings, 
the  cervix  altered  by  epithelioma  is  very 
well  depicted. 

Mr.  Doran  reported  that  the  uterus 
and  its  appendages,  when  removed, 
'  weighed  25  ounces  exclusive  of  the 
foetus,  and  measured   G  inches  in  lenTth.* 


174 


UTERINE   AND   OTHER  ABDOMINAL   TUMOURS 


'  The  upper  part  of  the  uterus  pre- 
sented no  abnormal  appearance;  ante- 
riorly, immediately  below  the  line  of 
reflexion  of  the  peritoneum  on  to  the 
bladder,  was  a  perfectly  horizontal 
lacerated  wound,  about  2  inches  in  -width, 
opening  into  the  uterine  cavity.  The 
cut  ends  of  the  uterine  artery  could  be 
seen,  on  each  side,  entering  the  iiterus  at 
its  lateral  and  inferior  part,  between  the 
anterior  and  posterior  peritoneal  coverings. 
The  OS  was  completely  encircled  by  a 
cauliflower  growth  which  extended  very 


little  into  the  uterine  cavity,  but  invaded 
the  cellular  tissue  to  the  right  of  the 
cervix.  The  portion  of  vaginal  -wall 
removed  formed  a  complete  but  very 
narrow  fringe  round  the  new  formation. 
This  growth,  when  examined  microscopi- 
cally by  Mr.  Eve  and  myself,  showed  all 
the  characteristics  of  epithelioma.  The 
right  ovary  contained  a  large  corpus 
luteum  of  pregnancy,  the  left  showed  two 
corpora  lutea  in  process  of  atrophy  ;  the 
stroma  of  both  was  normal  and  free  from 
dilated  follicles. 


'The  foetus  weighed  22^  ounces,  2.'j 
■ounces  lighter  than  the  uterus  and  its 
appendages;  it  measured  11  inches  and 
was  ill-nourished,  its  body  covered  with  a 
fine  down,  its  eyelids  gummed  together, 
and  its  nails  not  extending  to  the  tips  of 
the  fingers;  the  cord  was  9};  inches  in 
length.  The  conclusion  Avould  be  that  it 
was  about  a  week  over  the  Gth  month 
after  conception.' 

The  condition  of  the  patient  after  the 
operation  was  pretty  much  what  we  sec 
in  cases  of  ovariotomy  ;  rather  more  pain 
and  sickness  than  in  a  simple  case, 
but  less  than  in  very  complicated  cases. 
Three  small  opiates  were  given  within  G 
hours  alter  the  opeiation.     Sickness  re- 


mained troublesome  during  the  first  week, 
and  the  patient  was  nourished  with  injec- 
tions of  beef- tea  and  port- wine,  with  a 
little  laudanum  occasionally.  The  highest 
tempei'ature  was  101 '2°,  and  the  most 
rapid  pulse  12S.  During  the  night 
between  the  2Sth  and  29th,  S  days  alter 
the  operation,  opening  of  the  wound 
happened  from  frequent  vomiting ;  but 
the  stitches  Avere  carefully  replaced  by 
Mr.  Thornton  in  my  absence,  and,  though 
the  temperature  rose  soon  after  a  degree 
higher  than  it  had  been,  the  sickness 
ceased  in  the  afternoon. 

After  this,  though  some  of  the  stitches 
once  more  cut  through,  and  the  patient  was 
kept  in  a  state  of  irritation  by  an  accidental 


PARTIAL   AND   COMPLETE   EXCISION   OF   UTERUS 


175 


scald  on  the  leg  by  a  hot-water  cushion, 
there  was  not  much  to  remark  beyond 
a  rather  free  discliarge  of  serum  from  the 
vagina,  which  afterwards  became  puru- 
lent, and  ceased  within  the  third  week. 
Twenty-eight  days  after  operation  she 
was  moved  into  another  room,  but  before 
this  the  pulse,  temperature  and  digestive 
functions  had  been  quite  normal.  Urine 
passed  freely ;  slie  had  neither  pain  nor 
sicknes«,  and  she  slept  well.  She  returned 
to  her  home  in  Kent,  by  road,  on 
November  21.  When  asked  in  v;hat 
respect  this  confinement  differed  from 
those  of  her  5  children,  she  said  she 
had  always  suffered  from  vomiting,  but 
more  this  time  than  ever  before;  that  the 
chief  difference  was  that  she  had  no 
trouble  this  time  with  her  breasts,  and 
that  the  most  pain  was  from  the  scald  on 
her  leg.  Her  husband  called  on  me  in 
the  first  week  of  1 1SN2  and  told  me  that 
she  was  in  good  health,  gaining  strength, 
enjoying  life,  and  had  no  vaginal  dis- 
charge, pain,  or  irritation.  This  case 
then  distinctly  proves  that  a  patient  may 
recover  after  complete  excision  of  a  gravid 
uterus  and  both  ovaries,  and  Mr.  Doran's 
inspection  and  report  of  the  specimen  in 
the  College  Museum  encouraged  us  to 
expect  that  as  the  diseased  part  had  been 
completely  removed,  there  might  be  a 
considerable  jirolongation  of  life,  as  in 
cases  of  epithelioma  of  the  lip  or  anus, 
where  many  years  often  elapse  v/ithout 
any  new  morbid  growth,  and  to  be  hope- 
ful that  the  patient  might  escape  a  recur- 
rence of  the  disease.  But  she  came  up 
to  see  me  3  times,  at  intervals  of  a  fort- 
night, in  February  and  March  1(S82, 
with  a  very  suspicious  thickening  of  the 
vaginal  cicatrix,  although  the  general 
health  was  steadily  improving.  I  saw 
her  again  in  London  in  the  summer,  the 
disease  evidently  recurring  and  extend- 
ing upwards.  At  length  a  considerable 
mass  formed  in  the  left  iliac  fossa,  and 
she  died  13  months  after  the  operation. 

If  I  were  to  perform  such  an  operation 
again  I  should  modify  its  successive  steps 
according  to  the  gravid  or  non-gravid 
state  of  the  cancerous  uterus.  When 
non-gravid,  recent  experience  serves  to 
prove  that  extirpation  by  the  vagina  is 
the  safer  method.  "Wlien  gravid,  it  is 
possible  that  dilatation  of  the  cervix  and 
emptying  the  uterine  cavity  as  a  prelimi- 
nary measure  might  still  enable  the 
operator  to  act  through  the  vagina.     No 


case  so  treated,  as  far  as  my  knowledge 
goes,  has  been  recorded,  and  it  is  not 
easy  to  estimate  the  amount  of  risk 
which  would  have  to  be  encountered.  It 
seems  probable  that  in  nearly  all  cases  of 
gravid  cancerous  uterus,  either  the  abdo- 
minal, or  a  combined  vaginal  and  abdo- 
minal, operation  would  afford  the  greatest 
chance  of  success.  In  either  case  a  lai-ge 
elastic  catheter  or  a  canula,  through  the 
end  of  which  diverging  wires  expand, 
like,  but  shorter  than,  those  figured  on 
page  44,  would  serve  as  a  guide  and 
saft'guard  in  separating  the  uterus  from 
the  bladder  ;  and  if  the  abdominal  opera- 
tion should  be  selected,  a  large  ring 
pessary,  or  a  modified  Zwancke's  pessary, 
in  the  vagina,  would  afford  better  help  in 
making  the  section  of  the  vaginal  wall 
round  the  neck  of  the  uterus  than  the 
cotton  plugs  which  I  used.  Of  course 
the  vagina  ought  to  be  thoroughly 
cleansed  by  sulphurous  acid  or  som.e 
other  disinfectant. 

The  position  of  the  patient  during  the 
abdominal  operation  should  be  the  same 
as  ibr  ovariotomy,  but  for  a  combined 
vaginal  and  abdominal  operation  it  would 
be  convenient  to  separate  the  thighs  and 
flex  the  legs,  carefully  protecting  them 
from  cold.  In  any  case  a  strong  reflecting 
lamp  should  be  provided  and  ready  for 
use — say,  for  example,  a  good  carriage 
lamp  or  a  policeman's  bull's-eye,  until  a 
cool,  glowing  electric  light  is  perfected, 
such  as  we  may  obtain  by  means  of  an 
accumulator,  and  one  of  the  incandescent 
lamps  recently  described  and  used  by 
Dr.  Felix  Semon.  Something  of  this 
kind,  particularly  if  the  spray  be  u?ed, 
would  aid  greatly  when  vessels  are  being 
tied  or  sutures  passed,  unless  the  light  in 
the  room  is  unusually  strong. 

The  length  of  the  incision  in  the 
abdominal  Avail  need  not  be  so  long  as 
that  which  I  made,  if,  after  exposing  the 
uterus,  the  liquor  amnii  were  evacuated 
by  a  trocar.  The  uterus  might  still 
further  be  diminished  in  size  by  dividing 
its  wall  and  removing  the  foetus,  but  it 
would  be  very  desirable  to  avoid  any 
interference  Avith  the  placenta.  In  Porro's 
supra-vaginal  amputation  an  elastic  liga- 
ture passed  round  just  above  the  vagina 
might  be  used  Avith  advantage,  but  this  of 
course  is  out  of  the  question  if  the  cervix 
has  to  be  removed. 

After  AvithdraAving  the  uterus  from 
the  abdominal  cavity  a  few  sutures  should 


176 


UTERLNE   AND   OTHER  ABDOMINAL   TUMOURS 


be  inserted  so  as  to  bring  together  the 
edges  of  the  upper  part  of  the  opening  in 
the  abdominal  wall,  and  close  it  over  a 
flat  sponge.  This  prevents  the  intestines 
from  escaping,  and  protects  them  from  the 
cooling  of  the  spray  when  it  is  used.  I 
do  not  think  I  need  say  more  about  the 
suppression  of  hfcmorrhage  by  tying  the 
spermatic  arteries  or  the  use  of  pressure- 
forceps  than  will  be  found  in  my  narrative 
of  the  case.  By  careful  dissection,  and 
the  guide  of  a  catheter,  tlie  uterus  may 
be  separated  from  the  bladder  without 
mucli  danger,  but  I  do  not  yet  see  any 
mode  of  certainly  providing  against  the 
mischance  of  tying  or  dividing  one  or 
both  ureters.  I  fear  that,  with  all  possible 
care,  it  is  an  accident  which  may  occa- 
sionally prove  unavoidable. 

Mr.  Nunn  suggested  to  me  last  year 
that  removal  of  the  entire  uterus  would 
be  more  easy  if  the  organ  were  first 
divided  into  two  parts  by  cutting  it 
through  in  the  median  line  and  removing 
first  one  half  and  then  the  other.  He 
founded  this  proposal  on  his  anatomical 
observations  brought  before  the  Patho- 
logical Society  in  1S57,  and  published  in 
the  ninth  volume  of  the  '  Transactions.' 
Professor  Mliller,  of  Berne,  has  more 
recently  made  a  similar  recommendation, 
as  a  modification  of  total  extirjsation  of 
the  uterus  by  the  vagina.  He  has  not 
carried  his  proposal  into  practice ;  but  he 
thinks  that  the  necessary  ligatures  would 
be  more  easily  applied  and  be  much  less 
likely  to  slip  if,  after  drawing  down  the 
uterus,  it  can  be  'split  into  two  symmetri- 
cal halves  in  a  vertical  direction.  Then 
each  half  of  the  uterus  with  its  ligament 
could  be  drawn  backwards,'  the  ligatures 
applied,  and  the  uterus  cut  away  ('  Cen- 
tralblatt  fur  Gyniikologie,'  1882,  No.  8). 

When  the  abdominal  operation  is 
performed,  my  own  present  ieeling  is  in 
tavour  of  the  intra-peritoneal  method  of 
securing  the  vessels,  with  suture  of  the 
peritoneal  edges,  and  complete  closure  of 
the  incision  in  the  abdominal  wail.  Ols- 
hausen's  recent  experience  Avith  the 
elastic  ligature,  proving  that  the  ligature 
and  the  parts  compressed  by  it  may  be 
left  within  the  abdominal  cavity  with  most 
encouraging  results,  strengthens  my  im- 
pression in  favour  of  the  intra-peritoneal 
ligature.  But  I  iireely  admit,  at  the  same 
time,  tliat  recent  cases  by  Dr.  Bantock, 
Mr.  Thornton,  and  Mr.  Meredith  prove 
that  the  extra-peritoneal  treatment  of  the 


pedicle,  or  of  the  root  of  outgrowths  from 
the  uterus,  or  portions  of  the  uterus 
included  in  a  ligature  or  compressing  wire, 
may  be  very  safely  and  successfully 
efTected  by  Koeberle's  serre-noeud,  which 
is  ixsed  as  a  clamp,  and  prevented  from 
being  drawn  inwards  by  two  strong  pins 
passed  through  close  to  the  wire  loop, 
as  shown  in  the  preceding  chapter.  The 
edges  of  the  wound  are  then  carefully 
closed  around  the  stump. 

Most  operators  have  thought  it  neces- 
sary to  arrange  for  drainage  after  sepa- 
rating the  uterus  from  its  vaginal  attach- 
ments all  round.  But  I  do  not  see  that 
drainage  can  be  more  necessary  in  this 
operation  than  after  the  removal  of  uterine 
or  ovarian  tumours,  where  I  have  almost 
completely  abandoned  it.  I  believe  it  to 
be  more  important  effectually  to  close  the 
opening  between  the  peritoneal  cavity 
and  the  vagina  by  sutures,  than  to  use 
a  drainage-tube.  Indeed,  I  should  A'ery 
much  fear  that  the  latter  course  would  be 
hazardous.  It  has  also  been  proposed  to 
use  two  sets  of  sutures,  one  for  the 
vaginal  mucous  membrane  and  one  for 
the  peritoneum  and  broad  ligaments. 
My  present  feeling  is  that  the  vaginal 
sutures  are  unnecessary,  and  may  pos- 
sibly be  injurious  by  leading  to  collec- 
tions of  blood  or  serum  in  the  pelvic 
cellular  tissue. 

As  I  have  never  performed  either  a 
vaginal  or  a  combined  vaginal  and  abdo- 
minal operation  for  the  removal  of  a  non- 
gravid  uterus,  I  hesitate  to  say  much 
about  the  details  of  the  procedure ;  but 
I  think  it  extremely  probable  that  the 
operation  as  hitherto  practised  might  be 
very  much  simplified  by  drawing  down 
the  uterus,  separating  its  attachments  to 
the  vaginal  wall  all  round  as  near  to  the 
uterine  substance  as  possible,  or  exactly 
where  the  peritoneum  is  reflected  off  Irom 
its  walls,  securing  any  bleeding  vessel  as 
it  is  divided  by  pressure-forceps,  not 
using  any  ligatures,  but  leaving  the 
forceps  hanging  out  of  the  vagina  tor  2  or 
3  days  until  all  danger  of  hajmcrrhage 
has  ceased.  Since  I  first  published  this 
suggestion,  it  has  been  successfully 
tested  by  more  than  one  operator;  not 
altogether  superseding  ligatures,  but 
supplementing  them  where  ligatures 
could  not  be  easily  applied.  The  tbrceps 
might  be  so  arranged  or  tied  together  as 
to  serve  the  double  purpose  of  stopping 
bleeding   and    of    bringing    the    opposite 


rARTIAL   AND   COMPLETE  EXCISION   OF   UTERUS 


177 


■sides  of  tlie  vagina  together,  to  render 
peritoneal  sutures  superfluous.  It  is 
very  unlikely  that  if  the  forceps  were  left 
untouched  for  2  or  3  days  any  bleeding 
would  take  place]  and  if  it  did,  there 
would  be  no  more  difficulty  in  applying 
ti  ligature  than  in  the  first  instance. 
Further,  it  appears  to  me  that  sufficient 
iittcntion  has  not  been  paid  in  any  of 
these  operations  to  preliminary  compres- 
sion of  the  abdominal  aorta  by  tourniquet 
as  a  safeguard  or  preventive  of  bleeding, 
or  to  compression  of  the  aorta  by  the 
fingers  of  an  assistant  when  bleeding 
occurs  during  the  progress  of  the  opera- 
tion. It  is  also  probable  that  Mr, 
Davey's  plan  of  compressing  the  iliacs  by 
a  sound  passed  up  the  rectum  might  also 
■occasionally  prove  useful.  I  can  imagine 
it  to  be  quite  possible  in  persons  where 
the  abdominal  wall  is  lax,  either  by  a 
modified  tourniquet  or  by  the  hand  of  an 
assistant,  so  to  force  the  parietes  back- 
wards and  below  the  brim  of  the  pelvis, 
as  to  push  the  uterus  downwards,  keep 
the  intestines  in  the  upper  part  of  the 
abdominal  cavity,  and  at  the  same  time 
to  check  the  circulation  in  the  aorta  or 
the  iliacs,  and  thus  render  the  operation 
■almost  bloodless. 

More  than  50  years  ago,  Blundell, 
^fter  long  consideration,  based  upon  a 
t^eries  of  experiments  to  show  the  effect  of 
peritoneal  section  and  manipulation,  and 
fully  aware  of  the  difficulties  and  risks  of 
the  operation,  proposed  excision  of  the 
cancerous  uterus.  He  brought  forward 
his  views  with  no  very  sanguine  expecta- 
tions, and  simply  advocated  the  extirpa- 
tion as  a  last  resource,  which  might 
perchance  restore  a  measure  of  life  to  a 
few  of  the  many  women  who  were  menaced 
with  speedy  and  inevitable  death.  He 
carried  out  his  proposition  for  the  first 
time  in  September  182S.  He  did  4  cases, 
3  of  wdiich  proved  fatal — 2  within  6 
hours  of  the  operation,  1  after  39  hours — 
and  1  lived  a  year,  when  on  examination 
cancerous  masses  were  found  in  the  pelvis. 
All  Blundell's  operations  were  performed 
through  the  vagina.  A  very  interesting 
•account  of  them,  and  of  the  thoughts  and 
experiments  which  led  him  to  attempt 
them,  may  be  found  in  his  work  on 
■^  Obstetric  Medicine,'  published  in  1840, 
from  page  752  to  page  784. 

Three  deaths  out  of  4  cases,  and  a  re- 
currence of  the  disease  within  a  year  in  the 
only  patient  who  recovered,  will  account 


for  the  fact  that  the  idea  of  extirpation 
of  the  cancerous  uterus  was  not  revived 
in  England  until  1878,  when,  in  the 
Hunterian  Lectures  at  the  College  of  Sur- 
geons, I  made  known  Freund's  operation 
of  excision  through  the  abdominal  wall. 
It  has  not  yet  been  done  in  England  with 
any  good  results.    In  2  instances  of  which 

1  heard,  death  followed  after  a  short  inter- 
val ;  and  it  cannot  be  said  to  have  proved 
successful  in  Germany  and  Italy,  The 
experience  of  Freund  himself  and  other 
operators  up  to  the  end  of  1880  has  been 
collected,  and  Olshausen  has 'commented 
on  the  particulars  of  94  cases.  Of  these 
24  survived  the  operation  ;  but  in  nearly 
every  case  there  was  a  return  of  the 
disease,  and  in  some  of  them  after  a  very 
short  time — an  experience  corresponding 
almost  exactly  with  that  of  Blundell. 
Among  the  fatal  cases  some  died  of  shock, 
some  from  bleeding,  and  others  from  septic 
peritonitis.  Six  times  one  of  the  ureters 
was  divided.  In  2  other  cases  the  same 
accident  befell  both  ureters,  and  4  of  the 
operations  were  never  completed.  Imme- 
diate consequences  so  discomfiting,  and 
results  so  negative,  led  to  other  modes  of 
excision,  Delpech  had  a  long  time  before, 
in  1830,  indicated  a  combined  hypogastric 
and  vaginal  operation,  and  excision  by 
the  vagina  came  again  to  be  adopted. 
Olshausen  has  accumulated  the  history 
of  44  such  operations,  showing  an  out- 
come of  29  recoveries,  12  deaths,  and  3 
incomplete  operations.  We  have  here 
an  advance  of  more  than  40  per  cent,  in 
favour  of  this  procedure,  the  relative 
mortality  being  for  the  abdominal  section 
about  75  per  cent.  ;  that  for  the  vaginal 
extraction  not  quite  30  per  cent.  In  his 
own  practice  Olshausen  informs  me  that 
he  has  had  34  cases  of  total  extirpation 
of  the  uterus  by  the  vagina  up  to  the  end 
of  1884,   with  7  deaths — 3  from  sepsis, 

2  of  shock,  1  carbolic  poisoning,  and  1 
iodoform  poisoning.  Besides  these,  1  pa- 
tient, after  a  rapid  recovery,  died  quite 
suddenly  on  the  26th  day,  of  pulmonary 
embolism.  Three  cases  could  not  be  com- 
pleted on  account  of  firm  adhesions  be- 
tween the  uterus  and  rectum  or  bladder. 
Among  the  cases  where  there  has  been  no 
reappearance  of  disease,  2  years  have 
elapsed  in  2  cases,  in  1  case  2^  years,  and 
in  2  cases  3  years  ;  but  in  a  larger  pro- 
portion there  has  been  reappearance  in 
between  1  and  2  years. 

Professor  Billroth  of  Vienna,  in  a  letter 

N 


178 


UTEKINE   AND   OTHER   ABDOMINAL  TUMOURS 


to  me,  dated  Vienna,  November  18,  1881, 


'  Your  Porro-Freixnd  case  has  in- 
terested me  very  much,  as  a  similar  case  \ 
occixrred  to  me  3  months  ago.  A  strong  \ 
woman,  about  37  years  of  age,  4  months  \ 
pregnant,  had  extensive  carcinoma  ol:  the 
whole  cervix  and  part  of  the  vagina.  The 
whole  viterus  was  extirpated  by  the  vagina,  j 
Bleeding  was  considerable,  but  recovei-y 
Avas  rapid.  Unfortunately  it  was  necessary 
to  cut  away  part  of  the  bladder,  leaving 
a  hole  in  the  bladder,  and  a  large  hole 
(Rt'esenloch)  in  the  peritoneum.  I  stopped 
up  both  with  plugs  of  iodoform  gauze. 
These  were  left  for  8  days,  and  were  then 
removed.  There  Avas  no  sepsis,  but  heal- 
ing. The  A'esical  fistula  remains  for  future 
treatment.  In  another  case,  similar  except 
that  the  uterus  was  not  gravid,  one  ureter 
was  wounded.  The  large  peritoneal 
opening  was  plugged  with  iodoform  gauze, 
and  the  patient  recovered.  But  I  cannot 
heal  the  ureter  fistula.  Still  the  disinfect- 
ing power  of  iodoform  is  by  these  cases 
clearly  established.  By  no  other  means 
could  the  decomposition  of  the  woTind 
secretion  and  of  the  urine  flowing  through 
the  fistula  have  been  prevented,  and  death 
would  have  been  certain. 

'  Unfortunately  my  very  successful 
results  of  total  extirpation  of  the  carcino- 
matous uterus  per  vaginam  are  very  dis- 
appointing so  far  as  regards  relapse.  Even 
in  the  2  cases  just  described,  where  I 
extirpated  up  to  the  extreme  limits  of 
anatomical  possibility,  there  is  already 
recurrence.  Of  what  use  are  all  our  pains 
and  art!  '  ('Was  nutzt  da  alV  unsre  Millie 
und  Kunst  !  ') 

The  question  of  the  extirpation  of  the 
cancerous  uterus  has  a  very  different 
aspect  during  pregnancy  and  in  the  non- 
gravid  state.  For  a  pregnant  woman 
something  must  be  done  to  save  her  life. 
When  not  pregnant  the  question  is  one  of 
expediency,  not  of  necessity,  and  it  seems 
probable  that  there  will  be  very  few  cases 
in  which  a  positive  diagnosis  can  be  made 
before  the  disease  has  extended  so  far 
as  to  put  excision  beyond  all  reasonable 
hope  of  success.  In  the  early  stages 
diagnosis  is  often  doubtful,  and  so  serious 
an  operation  would  not  be  submitted  to  if 
recommended.  At  a  later  stage,  when  a 
more  positive  opinion  is  attainable,  and 
the  disease  is  apparently  confined  to  the 
cervix,  destruction  by  caustics,  or  the 
actual  cautery,  or  cutting  or  .«crapingaway 


of  the  diseased  parts,  followed  by  the 
application  of  the  chloride  of  zinc  or  some 
other  corrosive  agent,  or  arapiitation  of 
the  cervix,  are  all  methods  of  treatment 
which  would  have  to  be  considered  before 
proposing  total  extirpation.  And  although 
the  results  of  these  proceedings  have  not 
been  very  satisfactory  so  far  as  extension- 
or  recurrence  of  the  disease  is  concerned, 
yet  the  immediate  danger  to  life  is  very 
small  compared  with  that  attending  re- 
moval of  the  whole  uterus.  In  many 
cases  great  relief  is  obtained  for  a  time, 
loss  of  blood  and  offensive  discharges  are 
stopped,  pain  is  lessened,  and  the  general 
health  improved.  I  have  known  2  cases 
in  which,  after  removal  of  the  diseased 
cervix  and  the  use  of  the  actual  cautery, 
the  patients  died  about  5  years  later  on  ot 
some  other  disease,  no  return  of  that  of  the 
uterus  having  been  observed.  But  in  no 
other  case  Avhich  has  been  subjected  to 
the  same  treatment  by  me  has  the  relief 
lasted  many  months  ;  and  of  course  it  can 
only  be  expected  to  be  at  all  useful  when 
the  disease  is  confined  to  the  lower  segment 
of  the  uterus. 

In  cases  where  the  fundus  or  body  is 
affected,  if  any  surgical  measures  are  ad- 
missible, excision  by  the  vagina  Avould  be 
the  resource  to  wliich  our  present  know- 
ledge inclines  us.  And  if  it  be  done  suf- 
ficiently early  by  operators  who  have  made 
themselves  masters  of  all  the  details  of 
manipulation  by  practice  on  the  dead  body, 
and  by  carefully  stiidying  the  records  of 
the  cases  hitherto  published,  we  need  not 
despair  of  establishing  for  excision  of  the 
cancerous  uterus,  a  higher  scale  of  success 
with  fewer  failures  and  more  recoveries, 
and  of  being  able  to  rescue  from  their 
misery  as  large  a  proportion  of  our  patients 
as  any  surgeons  can  claim  to  do  wlien  they 
exercise  their  art  for  the  removal  of  cancer 
from  other  parts  of  the  body. 

I  have  nothing  to  add  as  a  result  of 
m}^  own  observation  or  practice  to  the 
above  sentences  published  in  1S81,  and 
all  I  can  gather  from  the  published  re- 
ports of  others  confirms  me  in  the  belief 
that  whether  a  cancerous  uterus  is  excised 
by  the  abdomen  or  the  vagina,  recurrence 
of  disease  is  the  rule :  and  it  becomes  a 
very  serious  question  if  any  patient  should 
be  advised  to  take  the  risk  of  shortening 
life — considering  that  it  is  about  80  per 
cent,  when  tlie  abdominal  operation  is 
performed,  and  from  20  to  30  per  cent, 
after    the    vaginal     operation — wlien    the 


PARTIAL   AND   COMPLETE   EXCISION   OF  UTERUS 


179 


gain,  even  in  the  most  favourable  cases, 
may  not  be  very  great,  perhaps  not  even 
greater  than  by  the  less  formidable  treat- 
ment proposed  in  the  preceding  paragraph. 

PORRO'S   OPERATIOX 

The  operation  now  commonly  Icnovvn 
as  Porro's  is  an  extension  of  the  Ca3sarean 
section,  and  mvist  replace  it  in  most  of  the 
cases  requiring    surgical   interference    of 
the  kind.     It  is  the  result  of  reasoning  and 
experimental  vivisection.     The  fatality  of 
the  Cccsarean  section  to  the  mother  was 
only  too  well  known,  and  its  causes  were 
not  doubtful.     The  idea  that  tlie  danger 
would  be  lessened  if  the  uterus  itself  as 
Avell  as  the  contents  were  taken  away,  was 
first  suggested  by  Cavallini,  of  Florence, 
in   17G8.     He   proved  the  possibility    oi 
doing  so,  as  well  as  the  fact  that  the  uterus 
is  not  necessary  to  the  life  and  health  of 
animals,  by  successfully  operating  on  dogs 
and    sheep.       Michaelis   of  Marburg,    in 
1809,  argued  that,  as  the  constitutional 
effects  were  less  after  the  gravid  uterus 
had  in  ignorance  been  cut  away  than  in 
cases   of  Cajsarean    section,    and   as   the 
uterus  was  an  organ  worse  than  useless  to 
a  Avoman  who  had  to  submit  to  any  such 
risk,  the  question  of  amputation  might  be 
entertained.     Blundell  and  others,  a  few 
years   later,   satisfied   themselves  that   it 
might  be  done  in  the  case  of  animals  with 
a  large    proportion    of    recoveries ;     and 
Storer  of  Boston,  in  18G9,  to  save  a  patient 
from   immediate    death    by    hasmorrhage 
during  a  Ca3sarean  section,  was  forced  to 
cut  off  the  uterus  as  well  as  a  large  fibroid 
rumour  .which    sprang    from    it.       The 
woman  had  been  3  days  in  labour  with  a 
l^utrid  fo3tus,  and  died  68  hours  after  the 
operation.     This  sufficed  to  show  that  the 
operation  itself  was  not  directly  fatal  in 
the  human  subject.     Porro  did  the  first 
premeditated  uterine  amputation  in  con- 
nection with  the  Cesarean  section  in  1876, 
and  saved  the  lives  of  both  mother  and 
child.     With  these  facts,  confirming  the 
justice    of   the    philosophical   suggestion, 
the    question    of  adopting   the  operation 
came  before  the  profession  for   decision. 
Opinion  was   divided,   but   the    days   of 
blind    opposition  were    over,    and  judg- 
ment was   more    calm    than   Avhen   pre- 
judice swayed  men  to  denounce  ovario- 
tomy.    The  practice  has  since  so  rapidly 
and  Avndely  spread  that  Dr.  Clement  God- 
son, at  the  end  of  1884,  Avas  able  to  tabu- 


late 152  cases,  with  (JG  recoveries  and  86 
deaths,  reported  from  11  different  coun- 
tries and  by  no  fewer  than  90  operators. 
This  table  of  Dr.   Godson's  is  a  marvel  of 
exactness  and  amplitude,  and  is  a  useful 
appendix  to  the  report  of  a  case  which  he 
himself  conducted    to    a    successful    end 
under  very  difficult  circumstances.     The 
patient  Avas  a  dAvarf,  24  years  of  age,  and 
Cesarean   section   Avould  haA'e   been   the 
only  means  of  saving  the  lives  of  mother 
and  child  if  this  operation  had  not  been 
undertaken.    It  was  performed  on  Novem- 
ber 22,  1882.     Precisely  similar  arrange- 
ments as  for  ovariotomy  Avere  made.     An 
incision   from  just   below   the    imabilicus 
to   about   2  inches  above  the  symphysis 
pubis  exposed  the  uterus.     As  Ioav  doAvn 
as  possible  on  its  anterior  Avail,  or  about 
the  junction  of  the  lower  Avith  the  middle 
third,  a  small  incision  Avasmade  just  large 
enough    to   admit   a   finger.     A  gush  of 
venous  blood  occurred,  and  the  membranes 
Avere  seen.     Dr.  Godson  inserted  the  tip 
of  each   forefinger   and    tore   the  uterus 
open  transversely.    The  membranes  were 
not  ruptured  by  this  manipulation.     He 
thrust  his  hand  through  them,   extracted 
the  child,  tied  the  cord  in  tAvo  j^Iaces,  and 
divided  it.     "While  he  Avas  thus  engaged 
Mr.   Thornton,    Avho    Avas   assisting    him, 
grasped  the  neck  of  the  uterus  Avith  his 
left  hand  and  applied  the  wire  of  Kceberle's 
serre-no2ud  Avith  the  right,  so  as  to  include 
both    ovaries  and   tubes  as  Avell  as  the 
uterus,  at  about  the  level  of  the  internal 
OS.     The  Avire  Avas  then  tightened,  and 
the  uterus  with    the  contained  placenta 
cut  aAvay.     Solid  perchloride  of  iron  was 
then  applied  to  the  raAV  surface  of  the 
stump.     Two  guarded  pins  were  passed 
through  it  above  the  wire,  and  a  strong 
silk   ligature  Avas  passed,  round  beneath 
them  for  greater  security.    The  abdominal 
Avail  Avas  then  closely  united  around  the 
pedicle,    as   in  ovariotomy.      The  serre- 
nosud  Avas  not  detached  till  the  loth  day. 
The  patient  regained  perfect  health,   her 
abdomen  shoAving  hardly  any  scar,  and  no 
depression  Avhere  the  pedicle  Avas  secured. 
All  I  need  to  say  noAv  about  the  Avay 
of  performing  Porro's  operation  is,  that 
it  is  not  advisable  to    make  an  inci.sion 
sufficiently  long  to  admit  of  the  uterus 
being  turned  out  entire  before   opening 
it.      The   opening   in    the    uterine    Avail 
should  be  out  of  the  A\'ay  of  the  placenta, 
and   Dr.   Godson's  mode  of  opening  the 
uterus     transversely,     just     above     the 

N  2 


180 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


internal  os,  is  probably  the  best-.  The 
child  should  be  extracted  in  the  readiest 
■way  possible,  and  without  any  attempt  to 
separate  the  placenta.  The  operator 
should  firmly  grasp  the  neck  of  the 
uterus  with  his  left  hand,  aiid  carry  an 
elastic  ligature  round  it  with  his  right. 
Perhaps  this  might  in  some  cases  be 
advantageously  done  before  tlie  uterus  is 
opened,  as  soon  as  any  bleeding  in  the 
abdominal  wound  has  been  stopped,  but 
without  making  any  strong  constriction 
until  after  the  child  has  been  removed. 
The  tying  of  the  cord,  and  any  necessary 
attentions  to  the  child,  should  be  entrusted 
to  an  assistant.  The  elastic  ligature  may 
then  be  fastened  by  a  simple  knot,  or  by 
being  passed  through  a  leaden  ring,  which 
is  compressed,  or  by  compression  with 
my  forceps.  The  uterus,  with  its  placenta 
undisturbed,  and  the  parts  inclosed  in 
the  ligature,  may  then  be  cut  away.  Of 
course  all  the  precautions  described  in 
ihe  chapters  on  Ovariotomy  and  Uterine 
Tumours,  for  preventing  the  escape  and 
exposure  of  intestines,  and  for  holding 
the  edges  of  the  opening  in  tlie  abdominal 
Avail  together  during  the  manipulation  of 
the  uterus  and  pedicle,  should  be  observed. 
The  uterus  having  been  cut  away,  and  a 
few  sutures  passed  through  the  edges  of 
the  upper  part  of  the  wound  in  the 
abdominal  wall,  supposing  the  extra- 
peritoneal treatment  of  the  stump  to  be 
preferred,  two  strong  guarded  pins  are 
made  to  transfix  the  stump  from  side  to 
side,  about  ^  an  inch  above  the  elastic 
ligature.  If  the  operator  is  unwilling 
to  trust  to  this  ligature  alone,  the  wire  of 
Kdiberle's  serre-noeud  may  be  passed  im- 
mediately behind  the  pins,  and  as  it  is 
tightened,  the  india-rubl)er  may  be  cut 
through,  or  left  as  an  additional  precau- 
tion, at  the  option  of  the  operator.  My 
own  belief  is  that  the  elastic  ligature 
alone  will  be  quite  sufficient.  In  either 
case  perchloride  of  iron  should  be  applied 
freely  to  the  stump,  as  soon  as  the  peri- 
toneal edges  of  the  opening  in  the  abdo- 
minal wall  have  been  sewn  closely  round 
the  peritoneal  coat  of  the  stump.  One 
suture  below  the  stump,  and  the  lowest  of 
those  above  it,  should  pass  through  not 
only  both  edges  of  the  abdominal  wound, 
but  also  the  peritoneum  of  the  stump. 
When  these  sutures  are  tightly  tied,  it 
is  almost  impossible  for  any  product  of 
the  decomposition  of  the  stump,  or  any 
liquefied    perchloride    of    iron,    even    if 


applied  in  excess,  to  run  down  beside  the 
stump  into  the  abdominal  cavity.  The 
skin  and  the  lower  part  of  the  wound 
should  be  protected  by  careful  packing 
with  iodoform  wool,  and  the  dressings 
applied  as  in  ovariotomy.  Careful  daily 
dressings,  changing  the  iodoform  wool, 
tightening  tlie  Avire  if  one  is  used,  re- 
moving portions  of  dead  tissue,  and  the 
fresh  application  of  perchloride  of  iron 
or  iodoform,  are  required  until  the  pedicle 
separates. 

Dr.  Godson's  table  is  arranged  chro- 
nologically. It  enables  us  to  trace  the 
quick  and  universal  adoption  of  the  opera- 
tion, and  gives  a  vivid  idea  of  the  changed 
condition  of  the  profession  when  we  note 
how  general  is  the  diffusion  of  surgical 
skill  and  aptitude  equal  to  dealing  with 
emergencies  so  pressing  and  an  under- 
taking so  difiicult  of  execution. 

The  details  and  references  of  152 
cases  of  true  Porro's  operations  are  given 
in  the  table.  It  covers  the  time  from  the 
date  of  Porro's  first,  on  May  21,  187G,  to 
the  end  of  1884.  A  calculation  of  the 
results  shows  a  mortality  of  56"57  per 
cent,  of  mothers,  and  a  gain  of  124  living 
children.  We  learn  from  the  table  three 
lessons  :  first,  that  as  some  form  of  septic 
peritonitis  was  the  cause  of  56  out  of 
the  80  deaths,  it  is  chiefly  to  ths  suppres- 
sion of  this  danger  that  we  are  to  look 
for  a  diminution  of  the  mortality  among 
the  mothers ;  secondly,  that  Ave  ought  not 
to  regard  the  operation  as  a  last  resource 
for  dying  mothers;  thirdly,  that,  as  a 
major  operation  of  surgery,  it  compares 
favourably  with  some  others  of  the 
same  or  even  less  importance,  and  that  it 
contrasts  A'ery  advantageously  Avith  the 
Cesarean  operation. 

I  have  great  pleasure  in  quoting  some 
of  the  remarks  added  by  Dr.  Godson,  and 
in  taking  the  opportunity  of  congratulat- 
ing him  upon  being  the  first  in  Great 
Britain  Avho  has  succeeded  in  saving  the 
lives  of  both  mother  and  child  by  the 
operation. 

Dr.  Godson  says,  in  reference  to  the 
number  of  deaths  after  the  operation,  that 
'  in  performing  it  only  as  a  dernier  rcssort 
lies  one  great  reason  for  such  a  high 
mortality.  Out  of  the  152  cases  you 
Avill  find  80  only  in  Avhich  the  patients' 
condition  Avas  "  favourable,"  in  which  the 
pedicle  Avas  not  dropped  in,  and  in  which 
the  success  of  the  operation  itself  Avas 
not  prejudiced  by  any  avoidable  accident. 


PAraTAL   A^^D   COMPLETE   EXCISION   OF   UTERUS 


ISl 


or  these  SO  cases,  52  recovered,  28 
died,  a  mortality  of  about  1  in  3.  The 
question  of  selection  should  be  based  on 
these  figures;  not  upon  a  summing-up  of 
total  results  without  regard  to  the  cir- 
cumstances, so  far  as  Ave  can  investigate 
them,  which  in  each  case  in/Iuence  the 
result.  It  is  manifestly  unreasonable  to 
include  in  the  same  category,  as  cases 
undertaken  under  fair  conditions,  opera- 
tions performed  when  tlie  patient  was 
almost  moribund  from  disease,  or  ex- 
hausted from  days  of  labour,  during 
which  the  soft  parts  had  been  bruised,  or 
lacerations  had  occurred  in  the  attempts 
to  deliver  by  means  of  the  forceps  or 
cranioclast.' 

And  again,  speaking  of  the  advantages 
of  Porro's  operation :  *  Looking  at  the 
table,  and  taking  from  it  the  results,  the 
first  idea  will  probably  be  not  altogether 
favourable,  for  out  of  the  152  operations, 
86  deaths  are  recorded  against  66  re- 
coveries. 

'  In  comparing  these  results  with  those 
of  the  old  Caisarean  operation,  I  would 
call  attention  to  the  following  astound- 
ing facts :  In  the  Vienna  Hospital,  for 
100  years  there  had  not  been  a  re- 
covery after  a  Csesarean  section;  whereas 
recently,  in  3  cases  of  Porro's  opera- 
tion performed  in  one  week  by  Professor 
Carl  Braun,  the  whole  of  the  patients 
recovered.  In  Italy,  the  old  Cesarean 
operation  was  almost  always  fatal.  Pro- 
fessor Chiara,  of  Milan,  writes  that  out  of 
62  cases  operated  upon  by  Porro,  Lazzati, 
Billi  and  himself,  only  3  recovered.  On 
the  other  hand,  nearly  half  (23  out  of  53) 
of  the  Porro's  operations  have  been  ruc- 
cessful,  notwithstanding  that  the  operation 
has  been  performed  by  as  many  as  35 
different  surgeons.  Again,  up  to  May 
20,  1879,  when  Professor  Tarnier  per- 
formed his  first  Porro's  operation  at  the 
Maternite  in  Paris,  ever}''  Cassarean  case 
had  proved  fatal  there  since  1787.  The 
condition  of  the  patient  was  most  \ni- 
favourable,  nevertheless  she  recovered. 
In  our  own  city,  I  know  that  my  late 
colleague.  Dr.  Greenhalgh,  performed 
Cajsarean  section  10  times,  with  only   1 


recovery ;  while  I  have  myself  seen  it 
performed  by  4  different  operators,  every 
case  proving  fatal.  In  Prague,  Professor 
Breisky  has  performed  Porro's  operation 
4  times;  in  each  case  the  woman  has  re- 
covered and  the  child  has  been  saved. 

'  The  advantages  claimed  for  Porro's 

operation  over  the  old  Caisarean  section 

are  these  : 

I         '1.  The    uterus    being   removed,  and 

j  the  stump  of  it  being  outside,  there  is  no 

I  danger  of  bleeding  within  the  peritoneum, 

or    of    exudation     of    lochia,    as    before, 

through  the  incised  uterine  Avail.     At  the 

time  of  operation,  the  risk  of  haemorrhage 

is  much  less,  for  as  soon  as  the  cervix  is 

constricted,   it  ceases,   and    this  may  be 

very  promptly  done. 

'2.  Should  bleeding  occur  from  the 
pedicle,  being  outside  it  is  under  control 
— an  advantage  which  is,  hoAvever,  sacri- 
ficed by  the  intra-peritoneal  method. 

'3.  The  uterus  and  ovaries  having 
been  removed,  the  dangers  arising  from  a 
subsequent  pregnancy  are  avoided.' 

In  the  above  summary  by  Dr.  Godson 
of  the  advantages  claimed  for  Porro's 
operation,  it  is  assumed  that  the  uterine 
stump  is  fixed  outside — that  the  supe- 
riority of  the  extra  over  the  intra-peri- 
toneal method  is  established — and  it  is 
quite  true  that  an  examination  of  the 
cases  tabulated  by  Dr.  Godson  tend  to 
confirm  this  conclusion.  Only  14  cases 
Avere  treated  intra-peritoneally,  and  of 
them  only  5  recovered,  Avhile  of  the  extra- 
peritoneal cases  there  Avere  59  recoveries 
to  79  deaths.  But,  in  my  opinion,  it  is 
not  at  all  improbable  that  further  trials 
of  the  intra-peritoneal  method,  by  elastic 
ligature  and  peritoneal  suture,  may  modify 
this  conclusion,  or  even  reverse  it. 
Whether  the  necessary  experimental  trials 
of  both  methods  are  in  this  country  to  be 
made  upon  Avomen  only,  or  upon  females 
of  some  of  the  lower  animals,  must 
depend  upon  the  manner  in  which  British 
physiologists  are  limited  in  their  re- 
searches by  the  officials  Avho  administer 
the  Act  of  Parliament  34  &  35  Vict,  c, 
98  (187G),  knoAvn  as  the  'Vivisection 
Act.' 


182 


UTERINE   AND  OTHER  ABDOmNAL  TUMOURS 


CHAPTER   in 


EXTIPvPATION    OF    THE    SPLEEN 


One  of  the  main  cliaracteristics  of  modern 
surgery  is  its  boldness  and  success  in 
dealing  with  the  organs  of  organic  life. 
Although  in  former  times  the  three  great 
cavities  were  punctured,  excision  of  the 
organs  therein  was  scarcely  thought  of  as 
a  means  of  saving  life.  The  Ca^sarean 
operation  was  done  with  more  regard  to 
the  rescue  of  the  child  than  that  of  the 
mother.  The  current  phrases,  'cutting 
for  the  stone,'  '  tapping,'  '  trephining,' 
mark  the  limitations  of  the  efforts  of 
ancient  art.  Relieving  pressure,  letting 
out  fluids,  and  getting  rid  of  a  foreign 
body  were  the  ends  accomplished.  Tu- 
mours of  the  brain  and  gangrenous  lungs 
brought  about  death  without  any  attempt 
to  avert  it,  and  the  abdomen  was  a  sort 
of  Alsatia  for  every  organ  it  sheltered. 
But  the  day  that  INIcDowell  ventured  into 
the  peritoneal  cavity  for  an  ovarian  tumour 
was  the  last  of  its  immunity.  He,  indeed, 
little  thought  to  what  his  act  would  lead  ; 
and  I  believe,  if  the  truth  were  told,  the 
generation  of  sui-geons  now  vrorking  out 
the  sequel  of  his  daring  are  not  a  little 
astonished  at  the  lengths  to  Avhich  it  has 
inspired  them  to  go.  A  short  summary 
of  Avhat  has  been  done  in  abdominal  sur- 
gery for  the  extirpation  of  diseased  organs, 
or  parts  of  oi'gans,  I  propose  for  the  fol- 
lowing chapters,  as  Ave  may  fairly  trace 
the  whole  extension  up  to  the  starting- 
point  of  the  peritoneal  invasion  by  ovario- 
tom)^ 

I  have  enlarged  upon  tumours  of  the 
uterus  and  its  appendages,  and  have 
shown  that  even  evisceration,  as  far  as 
regards  those  parts,  is  a  justifiable  and 
life-saving  proceeding.  Sir  Henry 
Thompson  has  written  upon  the  new 
surgery  of  the  bladder,  and  other  operators 
have  proved  how  successfully  they  are 
able  to  rectify  the  occasional  injuries  to 
that  organ  and  to  the  ureters. 

But  in  order  of  time,  the  spleen  was 
the  first  abdominal  viscus  that  was  brought 
under  notice  as  capable  of  being  dealt 
with  like  an  ovarian  tumour.  I  think 
we  may  look  upon  the  case  of  extirpa- 
tion of  the  spleen  attributed  to  Zaccarelli, 
in  1549,  as  apocryj)hal.  We  do  not  find 
anything   authentic  tiJl   182G,   in  which 


year  Quittenbaum,  of  Rostock,  removed  a 
diseased  spleen  from  a  woman,  who  died 
of  shock  in  G  hours.  Then,  in  1855, 
Kuchler,  of  Darmstadt,  reported  that  he 
had  done  the  operation  on  a  man  who 
had  enlarged  spleen  from  ague.  He  en- 
countered no  special  difficulty  in  his 
undertaking,  but  lost  the  patient  from 
ha3morrhage  2  hours  after  operation. 

INIy  attention  was  first  drawn  to  the 
subject  by  a  specimen  of  enlarged  spleen 
exhibited  at  a  meeting  of  the  Pathological 
Society  in  1862,  by  Mr.  Nunn. 

At  that  time  I  did  not  know  that  the 
operation  of  extirpation  had  been  per- 
formed on  the  human  subject.  I  believed 
that  it  had  not  been  attempted  in  Great 
Britain.  But  in  reasoning  about  the 
matter,  I  could  not  doubt  the  possibility 
of  safely  accomplishing  in  man  that  which 
presented  no  fatal  difficulty  in  dogs.  I 
saw  that,  in  such  cases  as  Mr.  Nunn's,  it 
was  the  enlarged  spleen  Avhich  directly 
killed  the  patient,  in  spite  of  all  remedies; 
and  so,  putting  together  the  facts  of  the 
fatality  of  the  disease,  the  proved  possi- 
bilities of  living  without  the  organ  in 
question,  and  of  getting  rid  of  it  by 
operation,  the  conclusion  could  not  be 
evaded  that  a  surgeon  who,  after  due  pre- 
paration, refused  the  responsibility  of 
such  an  extirpation  was  failing  in  his  duty. 
Recent  expeiience  in  ovariotomy  lent  force 
to  the  conviction  that  it  was  a  thing  to  be 
done,  and  a  earful  study  of  the  elaborate 
treatise.  *  Die  Extirpation  der  Milz  am 
jMenschen,'  by  Simon,  of  Restock,  con- 
firmed my  resolution  to  make  the  at- 
tempt. I  had  to  wait  for  the  occasion, 
but  in  the  autumn  of  1863  I  was  con- 
sulted by  a  lady  who  had  a  spleen  en- 
larged to  3  or  4  times  its  natural  size. 
There  had  been  no  attack  of  ague.  The 
face  was  very  pallid,  and  there  was  a  con- 
fiidcrable  excess  of  white  corpuscles  in  the 
blood.  The  spleen  rapidly  enlarged.  Sir 
W.  Jenner  and  Sir  Ranald  Martin  con- 
sulted with  me  in  the  spring  of  18G4,  but 
the  state  of  the  1  ilood  set  aside  any  serious 
consideration  of  the  question  of  operation. 
The  patient  died  in  March  18G5,  and  Mr. 
Mitchell  Clarke,  of  Clifton,  examined  the 
body   at   my  request,  with   the   express 


EXTIRPATION   OF   THE   SPLEEN 


183 


object  of  ascertaining  wLat  would  have 
been  the  mechanical  difficulties  encoun- 
tered if  the  large  spleen  had  been  removed. 
He  reported  that  'it  was  very  easily- 
drawn  through  a  long  incision  in  the 
linea  alba,  and  the  vessels  having  been 
tied  in  3  or  4  bundles,  it  was  detached. 
There  was  not  the  slightest  adhesion  to 
ixny  organ,  nor  to  any  other  part.'  Then 
came  other  patients  who  v/cre  not  so 
seriously  affected  by  the  tumour  as  to 
make  a  dangerous  operation  advisable. 

At  length  a  woman,  34  years  of  age, 
who  had  been  married  at  the  age  of  19, 
placed  herself  under  my  care,  evidently 
dying  from  a  large  spleen,  Avithout,  so  far 
as  I  could  discern,  any  other  disease.  She 
had  3  children,  the  youngest  of  whom  was 
born  1 1  years  before.  She  had  never  mis- 
carried. The  catamenia  had  been  regular. 
Though  weak  and  of  a  frail  family,  she 
had  been  as  well  as  usual  till  the  latter 
part  of  1864,  when  she  began  to  flag,  but 
it  was  not  till  April  18C5  that  any  swell- 
ing in  the  abdomen  was  noticed.  It  was 
first  observed  beneath  the  lelt  false  ribs, 
and  grew  downwards  and  to  the  right. 
At  my  first  visit,  in  October  18G5, 1  found 
the  spleen  extending  as  high  as  the  7th 
rib,  and  so  low  in  the  pelvis  that  it  could 
be  felt  by  the  vagina  in  front  of  the  litems. 
The  notch  was  distinctly  perceptible  a 
little  above  the  umbilicus.  On  the  right 
side,  beloAv  the  umbilicus,  it  extended 
within  3  inches  of  the  anterior  superior 
spine  of  the  ilium.  On  the  left  side  the 
posterior  border  was  felt  free  and  well 
defined  in  the  loin.  It  Avas  impossible  to 
ascertain  by  palpation  or  percussion  Avhere 
the  enlarged  spleen  and  left  lobe  of  the 
liver  met,  nor  could  any  enlargement  of 
the  liver  be  detected.  Some  dilated 
superficial  veins  ran  over  the  tumour 
and  left;  side  of  the  thorax  to  the  left 
axilla.  There  was  no  oedema  of  the  legs, 
nor  any  sign  of  dropsical  effusion  nor 
glandular  enlargement.  The  complexion 
was  rather  pallid,  but  the  lips,  gums,  and 
conjunctivae  Avere  of  a  good  colour — in- 
deed rather  liorid.  She  had  been  con- 
fined to  her  bed  for  nearly  a  month, 
owing  to  the  pain  in  the  abdomen  and 
general  uneasiness  ;  but  the  appetite  Avas 
tolerably  good.  There  Avas  a  tendency 
to  constipation.  I  explained  the  nature  of 
the  disease  to  the  husband,  and  said  that 
nothing  but  an  operation — which  had 
never  been  done  in  England,  and  only 
twice  abroad,    unsuccessfully — offered   a 


hope  of  saving  life.  I  saAv  her  at  intervals 
until  November  14.  During  three  Aveeks 
.she  had  been  trying  to  take  quinine, 
iron,  and  bromide  of  potassium.  The 
quinine  produced  headache.  The  cata- 
menia had  appeared  twice  Avithin  the  last 
month.  Her  nights  had  been  more  dis- 
turbed by  pain ;  she  had  a  little  cough, 
but  air  entered  both  lungs  freely.  The 
heart  Avas  pushed  a  little  upwards  and  to 
the  right.  The  urine  Avas  acid,  deposited 
urates,  and  Avas  free  from  albumen.  The 
spleen  Avas  now  rapidly  increasing  in  size. 
In  consultation  Sir  W.  Jenner  observed  a 
soft  anemic  cardiac  murmur,  and  a  small 
tumour  just  above  the  umbilicus,  to  the 
right  of  the  notch  in  the  spleen,  Avhich  Ave 
supposed  to  be  either  a  splenculus  or  a 
part  of  the  pancreas.  The  blood  Avas  care- 
fully examined  and  a  slight  excess  of  white 
corpuscles  Avas  noted,  but  not  greater 
than  is  often  observed  in  pale  persons. 

Sir  W.  Jenner  expressed  liis  opinion 
that  the  patient  could  not  live  long  if  left 
to  medical  treatment  only,  but  that  ex 
cision  of  the  spleen  did  give  '  the  shadow 
of  a  chance '  of  saving  life.  The  patient 
and  her  husband  considered  the  matter, 
and  I  performed  the  operation,  by  their 
desire,  on  November  20.  Mr.  Clover  ad- 
ministered chloroform,  and  I  Avas  assisted 
by  Drs.  Bowen,  Ritchie,  and  Wright.  1 
made  an  incision  Avhich  extended  5  inches 
above  and  2  beloAV  the  umbilicus,  along 
the  outer  border  of  the  left  rectus.  Tavo 
arteries  Avere  tied  before  the  peritoneum 
Avas  opened.  In  opening  the  peritoneum 
rather  a  large  arteiy  Avas  cut  across  in  a 
piece  of  omentum  Avhich  Avas  loosely 
adherent  between  the  surface  of  the 
spleen  and  the  abdominal  Avail.  The 
vessel  Avas  tied.  The  adhering  portion  of 
omentum  Avas  separated,  and  by  putting 
in  my  hand  and  turning  the  loAver  edge  of 
the  spleen  first  through  the  opening,  the 
Avhole  of  it  Avas  easily  removed.  The  in- 
testines Avere  prevented  from  escaping  by 
Dr.  Wright,  Avho  kept  the  edges  of  the 
opening  carefully  together  behind  the 
spleen,  Avhich  avus  held  only  by  the  ves- 
sels and  the  gastro-splenic  omentum.  I 
Avas  beginning  to  tAvist  the  spleen  round 
to  bring  the  vessels  into  a  sort  of  cord, 
preparatory  to  applying  a  ligature,  Avhen 
the  splenic  vein,  Avhich  Avys  as  large  as  a 
small  finger,  gave  Avay,  and  blood  ran 
freely  fi-om  the  spleen ;  but  none  was 
alloAved  to  enter  the  abdomen,  and  I  at 
once  inclosed  the  vessels  in  a  large  clamp 


184 


UTERI>^E   AND   OTHER   ABDOMINAL   TUMOURS 


and  cut  away  the  spleen.  Before  tying 
the  vessels,  temporarily  secured  by  the 
clamp,  I  passed  eight  silk  sutures  to  keep 
the  edges  of  the  incision  well  together. 
The  peritoneum  wns  thus  protected  and 
the  viscera  retained  while  1  was  dealing 
with  the  vessels.  These  Avere  tied  in  2 
bundles  above  the  clamp,  which  was  then 
loosened,  and  2  arteries  and  a  vein  were 
also  separately  tied  before  it  was  finally 
removed.  On  taking  it  off  I  found  that 
part  of  one  end  of  the  pancreas,  as  large 
as  the  end  of  a  thumb,  had  been  bruised 
by  it.  All  the  ligatures,  except  those  on 
vessels  in  the  abdominal  walls,  were  cut 
off  clcse  and  returned  with  the  included 
tissues.  The  sutures  were  then  tied,  and 
the  abdomen  was  well  supported  by 
plaster,  pads  of  lint,  and  a  bandage.  The 
patient  was  35  minutes  under  chloroform, 
had  shown  less  evidence  of  shock  than 
was  often  seen  during  ovariotomy,  and  her 
pulse  throughout  was  between  SO  and  00. 

The  spleen  is  now  in  the  Museum  of 
the  College  of  Surgeons.  It  weighed,  on 
removal,  G  pounds  5  ounces,  but  9  ounces 
of  blood  drained  out  of  it,  leaving  the 
weight  5  pounds  12  ounces.  It  measured 
11  inches  in  length,  (S  in  breadth,  and 
between  3  and  4  in  thickness. 

Reaction  was  .4ow.  There  Avas  not 
much  pain,  but  the  stomach  was  irritable 
and  the  kidneys  secreted  abundantly. 
Twelve  hours  after  the  operation  the 
pulse  rose  to  100,  and  the  patient  became 
restless.  There  was  some  vomiting,  no 
lympanites,  and  flatus  passed  readily  both 
by  mouth  and  rectum.  The  s^kin  con- 
tinued warm  and  moist,  and  there  was 
plenty  of  urine;  without  albumen.  The 
patient  was  fed  by  the  rectum,  but  at  times 
retained  in  the  stomach  some  milk  and 
soda-wattr. 

On  the  morning  of  the  2nd  day  there 
was  a  violent  spasm  of  the  diaphragm. 
The  pulse  rose  to  112,  with  hot,  dry  skin, 
chest  oppression,  and  some  abdominal 
pain.  This  was  relieved  by  oDium,  given 
internally,  and  there  was  quiet  sleep  for  a 
few  hours  till  3.30  of  the  3rd  day,  only 
waking  up  occasionally.  At  that  time 
there  Avas  a  violent  rigor,  commencing 
suddenly  Avith  a  feeling  of  cold  in  the 
back.  The  rigor  only  lasted  for  a  feAv 
minutes,  but  reaction  did  not  take  place 
for  half  an  hour,  and  Avas  followed  by 
profuse  perspiration.  During  the  day  the 
patient  was  able  to  take  milk  and  soda- 
water,  but  at  4  o'clock  in  the  afternoon  a 


second  rigor,  in  every  respect  similar  to 
the  former  one,  took  place.  The  rest  ol" 
the  evening  the  pulse  remained  at  120  to 
130,  and  the  urine  continued  to  be  secreted 
in  large  quantities,  notwithstanding  the 
violent  perspiration. 

On  the  morning  of  the  4th  day  6 
grains  of  quinine  Avere  given  before  the 
expected  attack.  There  Avas  no  rigor  and 
the  patient  slept  Avell.  The  pulse  Avas 
only  96.  During  the  day,  egg  beaten  up 
and  mixed  Avith  milk  Avas  given  and  re- 
lished. In  the  afternoon  I  removed  the 
stitches,  and  found  the  Avound  was  per- 
fectly united.  Some  more  quinine  was 
given,  but  as  it  produced  buzzing  in  the 
head,  it  Avas  discontinued. 

During  the  5th  day  the  patient  was 
remarkably  well.  She  Avas  able  to  enjoy 
the  milk  and  rusk.  Pulse  continued  about 
103,  rising  at  night  to  120.  Some  fluid 
freces  Avere  passed.  The  patient  also 
continued  Avell  during  the  Gth  day. 
Urine  in  abundance  Avas  secreted,  and  the 
bowels  acted  naturally  in  the  morning. 
Milk  given  freely.  In  the  afternoon  the 
bowels  began  to  be  irritable,  and  port- 
wine  Avith  10  drops  of  laudanum  Avas  in- 
jected into  the  rectum.  A  good  deal  of 
flatus  passed.  At  night  she  Avas  very 
cheerful  and  comfortable,  and  there  Avas 
some  colour  in  the  cheeks.  About  10 
o'clock  she  Avas  fed  moderately  and  slept ; 
but  about  1  in  the  morning  of  the  7th 
day  she  aAvoke,  complained  of  cold  and  of 
a  pain  in  the  back,  Avhich  .she  had  felt  at 
each  of  the  previous  rigors.  The  bowels 
acted  very  freely.  The  pulse  Avas  very 
feeble,  and  rose  to  150,  and  the  respira- 
tion to  44.  She  rapidly  became  Aveaker, 
and  died  about  4  hours  after  the  sudden 
change — 158  hours  after  the  operation. 

We  examined  the  body  12  hours  after 
death.  Decomposition  had  advanced  Avith 
unusual  rapidity.  Fluid  blood  and  air 
bubbled  from  the  superficial  veins  as  they 
were  opened.  The  Avouud  Avas  perfectly 
united,  but  the  cutaneous  edges  were 
separated  Avithout  difficulty.  Tlie  peri- 
toneal edges  adhered  much  more  firmly. 
Two  ligatures  on  superficial  vessels  came 
away  with  a  very  slight  pull.  A  few 
drops  of  pus  Avere  observed  in  the  track 
of  one  of  the  ligatures.  There  Avere  no 
signs  of  general  peritonitis  ;  scarcely  any 
serum,  and  not  a  trace  of  blood  being 
found  in  the  abdomen.  Redness  and 
effusion  of  lymph  Avere  entirely  limited  to 
the  seat  of  operation.     The  ligatures  on 


EXTIRPATION   OF   THE   SPLEEN 


185 


the  blood-vessols  were  found  Avidi  diffi- 
culty, being  overlapped  by  the  pancreas, 
which  was  large.  The  liver  also  was 
large.  The  kidneys  were  healthy.  Both 
pleural  cavities  and  the  cavity  of  the  peri- 
cardium contained  a  large  quantity  of 
dark  red  serum.  The  lungs  were  healthy, 
although  there  Avere  old  pleural  adhesions 
at  each  apex.  The  heart  was  large  and 
flabby,  and  contained  soft  clots,  which 
extended  along  the  pulmonary  artery  to 
the  second  divisions.  These  were  the 
only  clots  found  in  the  body,  the  blood 
elsewhere  being  thin  and  fluid,  and  air 
bubbling  out  wherever  a  vein  was  opened. 

I  did  not  remove  another  spleen  until 
1873.  The  patient  Avas  a  married  lady, 
42  years  of  age,  who  had  observed  a  small 
tumour  nearly  20  years  before.  It  had 
not  affected  the  general  health,  and  she 
was  in  no  way  incommoded,  till  1870, 
when  more  rapid  enlargement  took  place. 
Even  then  she  chiefly  complained  of  lassi- 
tude and  weakness  of  the  legs.  But  in 
September  1872,  when  I  was  first  con- 
sulted,, her  condition  was  such  as  to  bring 
forward  the  question  of  operation,  as  it 
was  clearly  a  case  of  enlargement  of  the 
spleen.  By  May  1873  all  repugnance  to 
the  proposition  had  given  Avay,  and  the 
patient  was  desirous  to  run  even  a  serious 
risk  of  losing  her  life,  rather  than  go  on 
in  her  then  miserable  state.  The  cata- 
menia  had  been  irregular  for  some  time, 
but  had  recently  reappeared.  No  notes 
were  furnished  to  me  as  to  any  blood  ex- 
aminations, but  there  was  no  history  of 
malarial  influence. 

I  went  to  Birmingham  to  do  the  opera- 
tion on  IMay  24,  and  was  assisted  by 
Mr.  Goodall,  Mr.  Bartlett,  and  Mr.  G.  B. 
Evans.  Dr.  Day  administered  methylene ; 
and  there  were  present  Dr.  Tracy  of  Mel- 
bourne, Dr.  Maxwell  of  Formosa,  China, 
and  Dr.  Chadwick  of  Boston,  U.S. 

I  have  little  to  say  about  the  operation, 
which  only  differed  from  that  in  the  first 
case  in  the  incision  being  along  the  linea 
alba  instead  cf  to  the  left,  and  that  I  tied 
the  splenic  artery  nearer  to  the  aorta. 
The  tumour  was  nearly  double  the  size  of 
the  first,  weighing  16  pounds  3  ounces 
soon  after  removal,  and  12  pounds  after 
all  the  blood  had  drained  from  it. 

There  was  much  sickness  and  restless- 
ness after  the  operation,  bvit  some  hours 
of  sleep  during  the  night,  with  the  skin 
freely  acting.  Next  day  the  perspiration 
was  profuse ;  sickness  continued,  but  there 


was  no  restlessness.  The  vomit  on  the 
2nd  day  '  assumed  a  coffee-ground  cha- 
racter,' and  the  abdomen  was  tympanitic, 
with  some  cessation  of  sickness.  The 
dark  vomit  reappeared,  and  on  the  3rd 
day  the  pulse  quickened,  and  she  began 
to  sink,  dying  about  70  hours  after  the 
operation.  These  symptoms  evidently 
indicate  septictcmia.  They  were  much 
more  frequently  observed  before  the 
adoption  of  the  antiseptic  precautions 
now  so  much  more  strictly  enforced  than 
in  1873.  1  have  little  doubt  this  patient 
would  have  been  far  more  likely  to  have 
recovered  if  the  operation  had  been  done 
with  all  the  safeguards  that  would  now 
be  used. 

No  post-mortem  examination  was  per- 
mitted. Mr.  Kichards,  of  the  General 
Hospital,  Birmingham,  examined  the 
tumour  and  made  drawings.  Tumour 
and  drawings  were  sent  to  the  Museum 
of  the  College  cf  Surgeons,  and  the  fol- 
lowing is  the  report  which  I  received 
li-om  Mr.  IJichards : 

'  The  enlarged  spleen,  of  which  the 
size  and  colour  are  accurately  represented 
in  the  painting,  weighs  12  pounds,  and  is. 
of  the  consistency  of  healthy  human  liver. 
The  surface  is  smooth.  The  finger,  passed 
over  the  surface,  is  found  to  ride  over  hard 
nodules  which  are  pretty  uniform  in  size, 
each  nodule  being  about  the  size  of  a 
cob-nut.  One  of  these  nodules,  together 
with  a  small  amount  of  intervening  tissue, 
is  enucleated  for  minute  examination. 

'  The  internodular  tissue  presents  the 
character  of  ordinary  splenic  pulp.  The 
nodule  has  neither  capsule  nor  limiting- 
membrane,  nor  large  vessels  going  to  it. 
It  is  almost  as  firm  and  tough  as  cartilage. 
On  section,  the  central  portion  is  yellow- 
like tissue  undergoing  caseation ;  the 
periphery  is  purple,  like  splenic  pulp. 
The  two  blend  insensibly.  Fresh  scrap- 
ings show  splenic  cells,  with  many  large 
cells  the  size  of  human  liver  cells,  con- 
taining a  little  granular  matter  and  one 
small  eccentric  nucleus.  The  cells  are 
nearly  imiform  in  size  and  shape,  and 
nearly  spherical. 

'  Microscopical  sections  of  the  nodule 
show  it  to  be  composed  of  splenic  cells, 
with  abundant  irregular  stroma  ;  here  and 
there  are  racemose  alveoli,  containing  the 
large  before-named  cells.  The  large  cells 
are  in  greatest  abimdance  at  the  centre  of 
the  nodule.  I  am  satisfied  that  the  affec- 
tion   of  the  organ  is  not  cancerous,  nor 


188 


LTERINE  AND   OTHER  ABDOMINAL  TUMOURS 


sarcomatous,    nor   any    form  of  amyloid 
disease.' 

The  3rd  and  Jast  time  of  my  remov- 
ing an  enlarged  spleen  was  in  June  1876. 
The    patient   was  a    married  woman,  27 
years  of  age,  sent  to  me  in  the  previous 
February  by  Mr.  Jenkins,  of  Oxford,  who 
in  the  August  of  1875  thought  he  heard 
the  foetal  heart  sounds,  but  as  they  were  not 
distinguished  afterwards,  he  advised  her 
to  see  me.     She  was  then  about  the  size 
of  a  woman  near  the  end  of  pregnancy. 
No  fluctuation  could  be  detected  in  the 
tumour,  and  after  a  too  hasty  examina- 
tion, I  said  it  was  a  case  where  tapping 
would  be  useless,  and  advised  removal  of 
the  tumour  as  soon  as  she  was  willing  to 
submit  to  operation.     I  did  not  see  her 
between  February  and  June.      In  June 
the  tumour  was  somewhat,  but  not  much, 
larger  than  in  February,  filling  the  whole 
of  the  lower  part  of  the  abdomen,  extend- 
ing upwards  under  the  left  false  ribs,  but 
on  the  right  side  only  half  way  between 
the  umbilicus  and  the  right  false  ribs — 
not    reaching  qiiite    across    to   the    right 
superior   spinous   process   of    the   ilium. 
The  OS  and   cervix   uteri  were  normal ; 
the  tumour  could  be  felt  by  the  vagina, 
and  when  pressed  up    on  the  right  side 
moved   the   cervix.      The  movements  of 
'the  tumour  Avere  not  much  influenced  by 
respiration.     No  distinct  fluctuation  could 
be  detected,  but  in  some  directions  it  was 
doubtful.     Lumbar  sounds  were  clear  on 
percussion  on  the  right  side,  dull  on  the 
left.       A    depression,    suggestive    of   the 
splenic  notch,  was  felt  about  o  inches  to 
the    right   of  the  umbilicus.     She  was  a 
healthy-looking    woman,    of    clear    com- 
plexion, and  not  emaciated.     The   cata- 
menia  were  regular,  neither  excessive  nor 
deficient.     I  have  not  much  to  say  about 
the    operation,    except   that   Dr.    Marion 
Sims  Avas  present,  and  that  the  tumour 
weighed  11  poimds,  or  7|  pounds  after  3:^ 
pounds  of  blood  had  drained   out   of  it. 
This  was  the  only  one  of  my  3  cases  in 
which  loss  of  blood  was  the  cause  of  death. 
The  reason  why  the  bleeding  escaped  my 
notice  at  the  time  of  operation  is  explained 
by  the  account  of  the  post-mortem  exa- 
mination ;   and  the  obvious  lesson  of  the 
case  is,  that  the  splenic  artery  should  be 
tied  before  it  divides  into  its  branches,  and 
as  near    the   aorta   as    it   can    be    done, 
without  cutting  off  blood  supply  to  the 
pancreas   and   left  side  of  the  stomach. 
Probably    Franzolini's  method   of  tying 


both  artery  and  vein  separately,  with  two 
silk  ligatures,  and  dividing  the  vessels 
between  the  ligatures  will  prove  to  be  the 
best. 

Eight  hours  after  death  the  body  ap- 
peared perfectly  white  and  bloodless,  and 
so  did  the  muscles  of  the  abdominal  wall 
when  cut  into.  After  taking  out  the 
sutures  the  incision  was  extended  upwards 
nearly  to  the  ensiform  cartilage,  and  a 
.short  incision  carried  outwards  on  the  left 
side,  just  above  the  umbilicus,  so  that  a 
good  view  of  the  parts  might  be  obtained 
without  in  any  way  disturbing  them. 

The  intestines  and  stomach  looked 
perfectly  Avhite,  and  the  latter  was  much 
distended  Avith  gas.  No  blood  nor  clot 
to  be  seen.  The  stomach  Avas  turned  up 
and  held  on  one  side  so  that  the  liga- 
tures could  be  seen,  and  they  Avere  found 
to  be  holding  firmly.  The  one  Avhich  Avas 
applied  by  transfixion,  and  tied  in  tAvo 
halves,  included  in  each  half  a  large  branch 
or  division  of  the  splenic  artery  and  the 
corresponding  veins.  The  one  Avhich  Avas 
applied  separately,  afterAvards,  included 
nothing  but  some  loose  cellular  tissue, 
found  to  be  a  part  of  the  gastrosplenic 
omentum.  Close  to  this  Avas  a  piece  of  the 
spleen,  about  the  size  of  a  Avalnut,  also 
held  merely  by  loose  cellular  tissue.  A 
considerable  quantity  of  bright  red  fluid 
blood  was  sponged  out,  and  at  least  a 
pound  of  dark  coagulum  Avas  then  re- 
moved, and  a  large  dark  mass  brought 
ijito  view,  Avhich  proved  to  be  a  quantity 
of  coagulum,  inclosed  in  a  bag  formed  by 
the  connections  of  the  pancreas,  duodenum, 
and  parts  included  in  the  first  two  liga- 
tures. On  incising  this  and  removing 
the  clot — of  Avhich  there  Avas  as  much  as 
6  to  8  ounces — the  points  from  Avhich  the 
main  ha?morrhage  had  occurred  Avere 
found.  They  appeared  to  be  some  of  the 
smaller  divisions  of  the  splenic  artery, 
including  the  vasa  brevia  and  a  small 
branch  passing  to  the  pancreas. 

The  chief  haemorrhage  liad  therefore 
occurred  from  divisions  of  the  artery,  the 
main  branches  of  which  Avere  included  in 
the  first  two  ligatures ;  but  the  trunk, 
before  bifurcation,  had  not  been  secured. 
The  posterior  part  of  the  peritoneal 
cavity  contained  some  clot  and  fluid  blood, 
and  the  pelvis  Avas  full  of  fluid,  which 
appeared  chiefly  blood.  The  Avhole  of 
the  haemorrhage  had  taken  place  origin- 
ally into  the  sac  named  above,  formed  by 
the  connections  of  the  pancreas,  duodenum, 


EXTIRPATION  OF  THE   SPLEEN 


187 


and  spleen,  and  when  this  would  hold  no 
more,  the  blood  had  escaped  from  an 
opening  in  it  posteriorly.  Hence,  until 
the  parts  were  turned  aside,  there  was 
no  appearance  of  the  extensive  htenior- 
rhage  which  had  taken  place. 

I  have  only  seen  one  case  of  a  splenic 
cyst,  and  that  was  in  a  lady  whom  I  at- 
tended several  years  ago  with  Sir  W. 
Jenner.  The  diagnosis  was  very  doubt- 
ful, owing  to  the  presence  of  gas,  as  well 
as  fluid,  in  the  cyst  before  I  tapped  it. 
The  contents  were  chiefly  decomposed 
blood,  with  very  fetid  gas;  but  by  di'ain- 
age  and  daily  injections  of  iodised  water 
for  more  than  a  month,  the  patient  quite 
recovered  and  remained  for  several  years 
in  good  health.  I  have  seen  2  other 
cases  of  enlarged  spleen  where  operation 
was  contemplated  ;  one  with  Dr.  Wilson 
Fox,  where  the  spleen  gradually  dimin- 
ished under  the  influence  of  reduced  iron  ; 
and  another,  a  young  lady  from  Trinidad, 
for  whom  I  made  an  exploratory  incision 
in  June  1883,  but  did  no  more  than  clear 
the  peritoneum  of  ascitic  fluid,  as  the 
spleen  was  not  very  large,  was  intimately 
connected  with  the  pancreas  and  the  liver, 
and  there  was  a  A'ery  clear  history  of  con- 
siderable variations  in  its  size.  She  went 
to  Dieppe,  and  I  heard  some  months 
afterwards  that  the  splenic  tumour  could 
scarcely  be  detected.  I  heard  lately  that 
she  married  in  1884,  and  is  now  well. 

I  arather  from  the  interesting  mono- 
graph  on  Splenectomy,  by  Franzolini.  of 
Udine,  published  in  1882,  that,  from  the 
first  case  by  Quittenbaum,  in  1836,  up  to 
Franzolini's  own  case  in  1881,  28  cases  of 
extirpation  of  the  spleen  in  the  human 
subject  had  been  recorded.  Twenty-two 
of  these  were  in  women,  4  in  men,  and  2 
doubtful.  One  was  a  simple,  and  one  an 
hydatid  cyst  of  the  spleen.  Four  cases 
are  described  as  movable  spleen  ;  all  the 
others  as  simple,  malarial,  or  leuka?mic 
hypertrophy.  Only  5  of  the  patients  re- 
covered— the  1st,  a  cyst ;  the  2nd,  a 
simple  hypertrophy,  the  tumour  weighing 
less  than  3  pounds;  the  3rd,  a  movable 
spleen,  the  size  a  little  more  than  normal ; 
the  4  th,  also  movable,  measuring  23 
centimetres  in  length,  12  in  breadth,  and 
G  in  thickness;  the  5th,  Franzolini's  own 
case,  where  the  Aveight  was  scarcely  over 
3  pounds.  The  tumours  in  my  own 
cases  appear  to  be  the  largest  yet  removed. 
Nearly  all  the  deaths  seem  to  have  been 
from    htemorrhage   and   collapse.     Crede 


has  collected  30  cases  up  to  1881,  most 
of  tliem  the  same  as  Franzolini's.  Of 
these  KJ  were  leukaimic,  and  all  died  ;  of 
the  remaining  14,  o  died  and  9  recovered ; 
of  the  9  recoveries,  in  1  the  spleen  it- 
self was  normal  and  free  in  a  peritoneal 
abscess,  in  4  the  spleen  was  simply 
hypertrophied,  in  2  movable,  or  what  is 
termed  '  wandering  spleen,'  and  2  were 
splenic  cysts. 

These  facts,  and  the  two  operations 
which  I  performed  after  my  first,  do  not 
lead  to  any  important  modification  of  the 
following  remarks,  made  in  commenting 
on  my  first  case,  and  published  in  the 
'  Medical  Times  and  Gazette,'  vol.  i.  18G4  : 

'  The  cases  of  Quittenbaum  and  Kiich- 
ler  had  tauglit  that  a  large  spleen  could 
be  easily  removed ;  but  as  1  patient  only 
lived  2  hours  and  the  other  only  6  hours, 
it  was  doubtful  whether  a  human  being 
would  recover  from  the  immediate  efiEects 
of  the  operation.  The  case  now  recorded 
does  at  least  make  this  addition  to  our 
knowledge. 

'  It  also  proves  that  neither  haemor- 
rhage nor  peritonitis  necessarily  follows 
the  operatiori.  Some  alteration  in  the 
blood,  which  becomes  fluid,  and  permits 
of  a  rapid  exudation  of  serum  into  the 
pleural  or  other  serous  cavities,  may  per- 
haps prove  in  other  cases,  as  in  this,  to  be 
the  chief  danger  to  be  dreaded. 

'  The  principal  difference  between  the 
operative  proceedings  of  Quittenbaum  and 
Kuchler  and  my  own  was  in  the  re- 
moval of  the  ends  of  the  ligatures  which 
secured  the  splenic  blood-vessels.  In  their 
cases  the  ends  of  the  ligatures  Avere  left 
and  brought  out  through  the  wound.  I 
had  found  a  similar  mode  of  dealing  Avith 
the  ligatures  which  secure  the  pedicle  in. 
ovariotomy  to  be  so  A^ery  rmsuccessful — 
the  threads  acting  as  setons  and  setting 
up  peritonitis — that  I  determined  (if  the 
clamp  made  much  pull  upon  the  stomach) 
to  cut  off  the  ends  of  the  ligatures  and 
return  them  AA'ith  the  included  tissues — a 
proceeding  Avhich  has  led  to  A^ery  good 
results  in  ovariotomy.  In  dogs,  two  ov 
three  turns  of  the  spleen,  tAvisting  the 
blood-vessels,  are  often  enough  to  stop 
bleeding  Avithout  any  ligature;  but  al- 
though this  may  answer  Avith  a  spleen  of 
natural  size  in  a  dog,  it  could  not  be 
thought  of,  except  as  a  preparative  for  the 
ligature,  in  the  case  of  a  large  spleen  in 
man.  But  my  trial  shoAvs  that  it  Avould 
be  better  not  to  attempt  it,  for  the  splenic 


188 


UTERINE   AND   OTHER   ABD03IINAL   TUMOURS 


vein  burst  before  one  turn  was  completed. 
If  I  were  to  oj^erate  again,  I  would  tie  the 
vessels  in  separate  bundles  as  they  enter 
the  spleen,  and  then  cut  away  the  organ. 

'  The  parallel  between  the  operation 
for  the  removal  of  an  enlarged  spleen  aud 
an  enlarged  ovary  ends  with  the  operation 
itself.  The  successful  removal  of  one 
ovary  is  frequently  followed  by  the  most 
jierfect  health  of  the  woman,  Avho  may 
bear  children  of  both  sexes.  Whether  a 
human  being  would  enjoy  good  health 
without  a  spleen  is  a  question  still  waiting 
for  a  satisfactory  answer.  Experiments  on 
other  animals  may  be  objected  to,  although 
the  impunity  with  which  the  organ  may 
be  removed  and  the  good  health  of  the 
animal  for  years  after  does  seem  to  imply 
that  the  offices  it  performs  cannot  be  of 
very  great  importance,  and  may  be  per- 
formed by  the  lymphatic  glands  or  some 
other  organs.  Dr.  Wilks  says  that  the 
spleen  may  be  "  shrunken  into  so  small  a 
compass,  and  surrounded  by  so  thickened 
a  capsule,  that  its  enlargement  seems  im- 
possible, and  its  appearance  would  suggest 
that  the  functions  of  such  a  withered 
organ  had  altogether  ceased.  Yet,  if  so, 
there  are  no  symptoms  to  indicate  its  loss." 
("  Guy's  Hospital  Reports,"  Third  Series, 
vol.  xi.  p.  41.) 

'  Many  cases  have  been  recorded  which 
prove  that  after  partial  or  total  removal 
of  the  spleen  by  accident  life  may  be  pro- 
longed, but  there  is  little  satisfactory  in- 
formation as  to  the  length  of  life  or  state 
of  health  of  the  individuals. 

'  In  one  remarkable  case  a  woman,  30 
years  of  age,  who  had  fever  in  January 
1711,  had  swelling  and  pain  in  the  leit 
side  of  the  abdomen,  followed  l)y  swelling 
of  the  left  foot  and  leg,  and  in  February 
by  a  ielid  discharge  from  the  uterus. 
For  the  next  four  months  she  became 
thinner,  and  fluctuation  Avas  detected  in 
the  abdominal  swelling.  Ferrerius  then 
made  a  puncture  3  fingers'  breadth  below 
the  umbilicus  to  the  left  side,  from  which 
a  discharge  of  fetid  pus  was  kept  up  for 
many  days.  A  second  and  larger  opening 
higher  up,  near  the  tunbilicus,  then  oc- 
curred spontaneously,  and  the  matter  was 
discharged  through  both.  The  patient 
became  nuicli  emaciated,  when  the  surgeon 
saw  a  bluish  body  at  the  upper  opening 
and  removed  it  Avithout  much  trouble.  It 
was  H  fingers  in  length,  2  in  thickness,  and 
the  same  in  breadth.  It  was  examined  by 
Fantoni,  and  found  to  be  the  spleen.    The 


patient  began  to  improve  at  once,  but  for 
several  days  a  portion  of  her  food  passed 
through  the  opening  near  the  umbilicus, 
as  if  the  abscess  about  the  spleen  had  been 
complicated  by  a  gastric  or  intestinal  fis- 
tula. But  the  wound  healed,  the  patient 
recovered  her  strength,  had  a  good  colour, 
the  catamonia  returned  regularly,  she  be- 
came pregnant,  and  bore  a  healthy  child ; 
but  from  this  time  the  abdomen  began  to 
swell  again,  and  during  a  year  different 
parts  of  the  body,  especially  the  head, 
Avero  attacked. 

'  This  is  one  of  the  most  complete 
accounts  we  have  as  to  the  state  of  health 
after  loss  of  the  spleen.  It  is  qi;oted  by 
Hecker  and  Simon  from  Fantoni's  "  Opus- 
cula  iMedica,"  published  at  Geneva  in  173s. 
Cases  in  which,  after  penetrating  Avounds 
of  the  abdomen,  tlie  Avhole  of  the  spleen  or 
portions  of  it  have  been  removed  are  on 
record,  but  I  have  only  been  able  to  meet 
Avith  tAvo  Avell-authenticated  cases  Avhere 
the  avhole  spleen  Avas  removed.  The  first 
Avas  in  1G78  by  Mathia ;  it  is  related  by 
CrUger  and  quoted  by  Simon.  A  Avatch- 
man,  23  years  old,  Avas  stabbed.  The 
spleen  protrtided.  The  vessels  were  tied 
and  the  spleen  ci;t  aAvay  3  days  afterwards. 
There  Avas  free  bleeding,  but  it  Avas  stopped 
by  a  styptic  poAvder,  and  the  man  Avas 
Avell  in  3  weeks.  The  divided  A'essels 
formed  a  lump  of  the  size  of  a  hazel-nut, 
and  adhered  to  the  cicatrix.  The  man 
returned  to  his  duties,  and  Avas  seen  in 
good  health  6^  years  after  the  accident. 

'  The  second  case  occurred  in  1815, 
and  is  recorded  by  Lenhossek  (Ilecker's 
"  Annalen,"  Berlin,  1  S2S).  A  youth  of  1 !) 
Avas  Avounded  in  the  abdomen.  The  spleen 
protruded,  and,  as  it  Avas  becoming  gan- 
grenous, it  Avas  cut  away  after  tying  the 
vessels.  The  Avound  healed,  and  in  iSlS 
the  man  was  quite  Avell. 

'  Cases  of  partial  excision  of  the  spleen 
are  much  more  numerous,  but  1  shall  only 
refer  to  one  recorded  by  Bcrthet,  in  1844, 
Avhere  a  man  lived  and  enjoyed  good 
healtli  for  13  years  after  a  Avound  followed 
by  hernia  and  extirpation  of  a  large  portion 
of  the  spleen.  He  died  of  acute  pneu- 
monia, and  after  death  only  a  small  piece 
of  spleen  Avas  found,  the  size  of  a  hazel- 
nut, Avhich  Avas  adhering  to  the  stomach. 
The  case  is  quote  I  by  Gray  and  Simon 
from  the  "  Archives  Generales  de  Mede- 
cine,"  1S41.  These  cases  of  partial  exci- 
sion are  of  farlessphysiological  importance 
than  cases  of  total  excision ;  for  Dr.  Crisp 


EXTIRPATION  OF   THE   SPLEEN 


189 


has  shown  that  if  a  portion  of  the  spleen 
be  left  it  may  grow,  and  the  organ  may  be 
more  or  less  completely  reproduced.  This, 
Dr.  Wilks  observes,  is  "  quite  in  harmony 
,^vilh  the  simple  hypertrophy  of  the  spleen, 
for  if  an  organ  of  a  given  size  can  grow  to 
several  times  its  normal  standard,  there 
appears  no  reason  why  a  small  portion  re- 
maining after  an  operation  should  not 
again  grow  to  the  original  dimensions  " 
{pp.  cit.  p.  40).  This  remark  prepared 
me  to  leave  a  portion  of  the  spleen  in  my 
patient,  if  I  found  it  possible  to  do  so,  or 
the  splenculus,  if,  as  wc  thought  probable, 
it  had  existed.  Possibly  it  niiglit  be  ad- 
visable to  act  on  this  principle  in  a  case 
where  it  could  be  done  safely. 

'  If  it  be  asked,  "  In  what  cases  may 
an  enlarged  spleen  be  excised  ?  "  the  con- 
clusion would  seem  to  be  that  they  can  be 
only  very  few.  If  a  large  spleen  were 
wounded,  or  ruptured,  or  caused  obstruc- 
tion of  intestine,  the  operation  might 
be  the  only  means  of  saving  life.  But  in 
the  absence  of  some  such  accident  imme- 
diately endangering  life,  it  is  not  often 
that  a  patient  has  a  large  spleen  and  has 
not  some  co- existing  disease  of  liver, 
kidneys,  or  lymphatic  glands,  which  would 
•either  prevent  the  success  of  the  operation, 
or  would  destroy  the  patient  soon  after 
the  recovery  from  its  immediate  effects. 
Where  no  such  disease  co-exists,  then 
probably  the  ill  effects  of  the  large  spleen 
nre  either  too  slight  to  warrant  a  dan- 
gerous operation,  or  the  general  condition 
of  the  patient  is  too  bad  to  give  any  reason- 
tible  prospect  of  recdvery.  This  is  espe- 
•cially  true  Avith  regard  to  that  form  of 
enlarged  spleen  wliich  follows  ague. 
Either  it  is  amenable  to  treatment,  or,  if 
the  patient  be  ill  enough  to  induce  the 
surgeon  to  think  of  an  operation,  the 
general  health  is  so  broken  up  and  the 
blood  is  so  altered,  rhat  a  simple  cut  or 
ulcer  may  lead  to  dangerous  bleeding,  and 
a  fortiori  a  serious  0[ieration  would  most 
likely  be  fatal.  The  relation  which  the 
enlarged  spleen  after  ague  bears  to  the 
accompanying  leukaemia,  bydra^mia,  or 
melanoBmia,  is  a  prf)l»lem  which  has  still 
to  be  solved;  and,  ev>-n  in  the  leukaemia 
which  occurs  independently  of  ague,  it  is 
still  a  matter  of  doiii)t  whether  the  en- 
largement of  the  spl'en  or  the  alteration 


in  the  blood  bears  always  the  same  relation 
of  cause  and  effect.  But  as  it  has  been 
proved  experimentally  that  the  blood 
which  issues  from  the  spleen  by  the  splenic 
vein  does  contain  a  much  greater  number 
of  white  corpuscles  than  the  blood  in  tlie 
general  circulation,  and  it  is  known  that 
in  simple  hypertrophy  of  the  spleen  there 
is  a  great  increase  in  the  proportion  of 
white  to  red  corpuscles  in  the  blood 
throughout  the  body,  it  woidd  seem  to  be 
a  fair  presumption  that  removal  of  the 
spleen  by  cutting  off  the  supply  of  the 
white  corpuscles  which  are  in  excess,- 
might  save  the  life  of  persons  who  would 
otherwise  die  of  leukaemia.' 

In  1882,  Dr.  B.  Credo  brought  a  case 
of  extirpation  of  the  spleen  before  the 
German  Surgical  Congress  at  Berlin,  and 
published  a  valuable  paper  on  the  subject 
in  '  Langenbeck's  Archiv  '  in  1883.  He 
removed  in  September  1881,  from  a  man 
44  years  old,  a  spleen  which  weighed  about 
15  ounces,  after  about  56  ounces  of  fluid 
had  been  withdrawn  from  a  cyst.  He 
tied  all  the  vessels  separately  with  cat- 
gut, cutting  off  the  ends  close  to  the  knots. 
The  patient  recovered,  and  10  months 
after  the  operation  was  in  good  health, 
working  as  a  mason.  His  conclusions, 
after  a  careful  study  of  the  whole  subject, 
agree  very  nearly  with  my  own  in  18G4 
repeated  above,  but  with  additions  to  the 
effect  that  in  the  animal  organism  the 
spleen  serves  for  the  transformation  of  the 
white  corpuscles  of  the  blood  into  red, 
and  that  adults  are  not  injured  by  loss  of 
the  spleen,  although  its  removal  may  cause 
transitory  disturbance  in  the  formation  of 
the  blood,  and  swelling  of  the  thyroid 
gland  which  may,  for  a  time,  supply  the 
functions  of  the  spleen. 

The  discussions  here,  which  followed 
the  cases  of  Mr.  Hayward  in  1882,  and 
of  Mr.  Spanton  in  1883,  led  to  the  conclu- 
sion that,  in  cases  of  leucocythajmia,  the 
enlarged  spleen  should  certainly  not  be 
removed  until  after  the  free  use  oi:'  re- 
duced or  dialysed  iron;  and  that  the 
best  results  are  to  be  hoped  for  in  cases 
of  simple  or  malarial  hypertrophy.  The 
alternative  proposal  of  tying  the  splenic 
artery  cannot  be  tried  on  the  human 
subject  until  sufficient  experiments  on 
the  lov/er  animal  have  been  made. 


190 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


CHAPTER   IV 
THE    OPERATIVE  SURGERY  OF  THE  KIDNEY 

KEPHKORAPHY  ;  TAPPING  AND  DRAINAGE  ;  NEPHROTOMY  ;  NEPHROLITHOTOMY  ;  NEPHRECTOMY 


Students  who  have  followed  the  exten- 
sion of  the  domain  of  peritoneal  surgery, 
from  the  revival  of  ovariotomy  to  the 
removal  of  uterine  and  splenic  tumours, 
however  great  their  expectations  as  to 
further  progress,  must  still  be  surprised 
at  the  very  rapid  development,  Avithin 
the  last  few  years,  of  the  surgery  of  the 
kidney,  even  more  than  that  of  other  de- 
partments of  abdominal  surgery.  Twenty 
years  ago  tapping  a  renal  cyst  was  a 
novelty.  An  abscess  occasionally  made 
Avay  for  the  passage  o£  a  renal  calculus  ; 
very  rarely  a  tumour,  supposed  to  be 
ovarian  or  uterine,  was  found  to  be  renal 
after  an  operation  had  been  begun,  and 
the  operation  Avas  either  left  incomplete 
or  the  kidney  Avas  remoA^ed  Avith  the 
tumour,  after  tying  the  renal  A'essels,  as 
the  only  mode  of  stopping  bleeding;  or 
the  fact  of  the  removal  of  the  kidney 
was  not  discoA^ered  imtil  after  the  com- 
pletion of  the  operation.  On  the  last 
contingency  a  useful  purpose  Avas  served, 
as  experiments  on  the  loAver  animals 
proving  that  one  kidney  might  be  re- 
moved Avithout  serious  ill  consequences, 
and  that  the  remaining  kidney  fulfilled 
all  the  necessary  excretory  functions,  Avere 
confirmed  by  the  condition  of  the  patients 
Avho  had  been  subjected  to  such  an  unin- 
tended operation.  One  such  case  occurred 
to  me  18  years  ago.  It  has  been  included 
in  Mr.  Barker's,  and  in  other  tables;  and 
all  I  need  say  of  the  case  noAv  is,  that, 
although  the  patient  died  of  septictcmia, 
the  removal  of  the  kidney  did  not  appear 
to  have  had  any  special  influence  on  the 
progress  of  the  case.  There  Avas  nothing 
in  the  lU'inc  after  operation  unusual  after 
ovariotomy.  This  Avas  very  carefully 
examined,  as  the  Avhole  of  the  left  kidney 
and  the  ureter  Avere  known  to  have  been 
removed,  together  Avith  a  solid  tumour 
which  Aveighed  !]_,  pounds,  and  a  cyst 
which  had  contained  IG  pints  of  fluid. 

Many  years  before  this  case,  in  1848, 
I  opened  a  perirenal  abscess  in  the 
loin  of  a  sailor  in  II. M.S.  '  Tra- 
falgar,'  and  finding  a  renal  calculus  on 
probing  the  abscess,  easily  removed  it; 
and  another  a  few  days  afterAvards.     In 


185-4,  I  exhibited  at  the  Pathological 
Society  a  calculus  found  by  Dr.  Bence 
Jones  to  consist  of  uric  acid,  which  I  had 
removed  after  opening  an  abscess  by  the 
side  of  the  rectum  of  a  gentleman.  It 
had  no  doubt  been  arrested  just  Avhere  the 
ureter  passes  through  the  coats  of  the 
bladder,  as  there  Avas  free  escape  of  urine 
for  some  days  after  its  removal,  though 
this  gradually  ceased,  and  there  was  no 
further  trouble.  Twice  since  I  have  re- 
moved a  renal  calculus  from  the  loin 
after  opening  an  abscess. 

Fifteen  years  ago  another  case  taught 
us  to  Avhat  a  large  size  tumours  of  the 
kidney,  or  closely  connected  Avith  it,  may 
attain.  It  Avas  also  illustrative  of  the 
difficulties  surroimding  the  question  as 
to  the  point  of  origin.  A  single  Avoman, 
aged  35,  Avas  admitted  into  the  Samaritan 
Hospital  in  December  1870,  Avith  the 
abdomen  greatly  enlarged.  There  Avas 
extreme  oedema  of  the  abdominal  AA'alls. 
Fluctuation  Avas  scarcely  perceptible,  and 
only  doubtful  in  the  loAver  part  of  the 
abdomen ;  there  AA^as  no  crepitus,  and  the 
sounds  on  percussion  Avere  dull  all  over 
the  swelling.  The  uterus  appeared  to 
be  small,  normal  in  size,  and  movable. 
No  tumour  could  be  felt  in  the  pelvis. 
She  had  gradually  attained  her  very  great 
size  since  the  spring  of  1870.  The  tume- 
faction of  the  abdominal  Awalls  Avas  too 
great  to  admit  of  any  satisfactory  diag- 
nosis as  to  the  nature  of  the  tumoiir. 
This  could  be  only  ascertained  by  an  ex- 
ploratory incision,  Avhich  Avas  accordingly 
made  l:)et\veen  the  umbilicus  and  sym- 
physis pubis  to  the  extent  of  6  inches. 
Much  serous  fluid  escaped,  and  3  or  4 
superficial  vessels  Avere  tied.  Four  or  5 
pints  of  clear  scrum  floAved  out  Avhen  the 
peritoneal  cavity  Avas  opened,  and  a  solid 
tumour  was  exposed,  very  firmly  adherent 
and  Avascular  on  its  surface.  One  large 
vein  at  the  upper  part  bled  so  freely  that, 
after  vainly  trying  to  apply  ligatures  (for 
the  soft  granular  tissue  gave  Avay  before 
the  silk),  I  used  the  actual  cautery  and 
solid  perchloride  of  iron.  The  Avound 
Avas  closed  Avith  sutures  and  long  bands  of 
strapping.     It    did    not   unite  Avell,   and 


OPERATIVE   SURGERY   OF   THE  KIDNEY 


191 


after  2  or  3  Aveeks  it  opened,  and 
allowed  the  tumour  to  protrude  a  little. 
There  was  continued  drainage  of  serum 
from  the  gaping  incision,  and  from  punc- 
tures made  at  various  times  in  the  legs 
and  thighs,  which  relieved  the  urgent 
dyspnoea  and  prolonged  life ;  but  the 
patient  gradually  got  weaker,  and  died 
8  Aveeks  after  the  operation. 

The  tumour  Avas  found  adherent  to 
the  abdominal  Avails,  to  the  liver,  omen- 
tum, and  descending  colon.  Behind,  it 
v/as  inseparably  connected  Avith  the  right 
kidney,  which  had  to  be  removed  Avith 
it.  The  tumour  alone  Aveighed  84  pounds. 
The  uterus  and  both  ovaries  Averehealth3\ 
Dr.  Wilson  Fox  reported  that  the  tumour 
was  'fibro-plastic,'  that  the  right  kidney 
could  only  be  separated  from  it  by  cn.reful 
dissection,  and  that  it  probably  originated 
in  the  kidney,  or  in  the  peritoneum 
covering  it.  Portions  of  the  tumoiu*  are 
preserved  in  the  Museum  of  UniA'ersity 
College. 

In  going  over  tables  of  operations  on 
the  kidney,  it  is  interesting  to  remark 
that,  Avhile  20  years  ago  a  large  proportion 
of  the  operations  Avere  performed  after 
an  error  in  diagnosis,  during  the  last 
few  years  a  A^ery  correct  diagnosis  before 
operation  has  been  the  rule,  and  a  mistake 
an  exception. 

In  1877  I  Avas  led  into  error  in  a 
patient  Avho  Avas  admitted  into  the  Sama- 
ritan Hospital,  supposed  to  be  the  subject 
of  an  ovarian  cyst,  Avith  a  history  of  3 
tappings  Avithin  the  preceding  5  years,  of 
44,  46,  and  52  pints  of  fluid,  by  surgeons 
Avho  had  no  doubt  about  the  fluid  being 
ovarian.  After  incision  and  removing  31 
pints  of  fluid,  and  more  than  a  pound  of 
cyst  Avail,  it  Avas  found  impossible  to  get 
aAvay  the"  rest  of  the  cyst.  A  drainage- 
tube  was  inserted,  and  the  patient  died 
on  the  5th  day.  The  cyst  Avas  clearly 
one  of  the  left  kidney,  the  main  cavity 
being  formed  by  one  of  the  calyces. 

Among  the  affections  of  the  kidney 
which  most  frequently  come  under  our 
notice,  I  may  mention  painful,  moA^able, 
or  floating  kidney,  hydronephrosis,  pyo- 
nephrosis, formation  of  stone  in  the 
kidney,  cystic  degeneration,  growth  of 
hydatids,  tumours  either  in  the  substance 
of  the  kidney  or  closely  attached  to  it. 
For  information  on  the  questions  of  diag- 
nosis Avhich  come  up  in  connection  Avith 
these  cases,  I  may  refer  to  the  chapter 
on  Differential  Diaixnosis  in  Part  I. 


MOVAELE    OR    FLOATING    KIDNEY 

forms  an  abdominal  tumour  occasionally 
tender  on  pressure,  and  painful  itself,  but 
more  frequently  neither  tender  nor  pain- 
ful, and  only  causing  uneasiness  in 
patients  or  anxiety  in  their  medical 
attendants,  because  of  the  uncertainty  as 
to  the  precif^e  nature  of  the  tumour  and 
the  possible  future  consequences.  When 
assured  that  the  tumour  is  nothing  more 
than  a  kidney  Avhich  is  too  movable,  and 
that  nothing  more  need  be  recommended 
than  an  abdominal  belt,  most  patients 
are  perfectly  satisfied.  Occasionally  the 
kidney  is  somcAvhat  enlarged  and  tender, 
but  this  is  mostly  the  eifect  of  iinnecessary 
handling,  and  disappears  with  rest  and 
quietness.  Sometimes  a  mass  of  hard 
fgeces  in  the  colon  curiously  resembles  a 
movable  kidney,  Avhich  may  also  be 
simulated  by  a  cancerous  groAvth  involv- 
ing some  part  of  the  intestines.  But  I 
have  seen  a  great  many  cases  Avhere  I 
have  excluded  these  and  other  sources  of 
fallacy,  and  have  convinced  myself  that 
one  or  both  kidneys  Avere  abnormally 
mobile.  In  Avomen,  I  have  almost  always 
found  that  it  Avas  the  right  kidney.  I 
attended  a  lady  Avith  Dr.  Wilson  Fox, 
seeing  her  from  time  to  time  for  several 
years,  on  account  of  a  tumour  Avhich  Ave 
both  believed  to  be  a  movable  I'ight  kid- 
ney. It  could  be  pushed  into  the  loin, 
and  across  the  abdomen  as  far  as  the 
umbilicus,  and  in  size  and  shape  exactly 
resembled  the  kidney.  At  length  she 
began  to  suffer  from  an  ei:ilargement  of 
the  left  ovary.  This  attained  a  consider- 
able size,  and  I  removed  it.  Taking  the 
opportunity  of  examining  the  supposed 
movable  kidney,  I  found  it  AA'as  the  right 
ovary,  lying  just  above  the  right  kidney, 
Avith  a  slender  pedicle  at  least  a  foot 
long.  In  size,  shape,  and  consistence  it  re- 
sembled a  kidney,  and  I  removed  it.  The 
patient  recovered,  and  is  still  quite  well. 
In  other  cases  of  supposed  moA^able  kidney, 
I  have  found  that  the  tumours  were  pedun- 
culated outgroAvths  from  the  uterus,  but 
I  have  no  doubt  Avhatever  that  movable 
kidneys  are  not  unfrequently  met  Avith. 
I  have  never  myself  knoAvn  them  cause 
sufiicient  inconvenience  even  to  raise  the 
question  of  operative  interference.  But 
there  are  many  cases  on  record  where 
they  have  led  to  nephrectomy,  or  to  the 
operation  of  fixation,  recently  styled 
'  nephroraphy.'     Never   having  yet  seen 


192 


UTERINE  AND  OTHER  ABDOMINAL  TUMOURS 


the  necessity  of  either  removing  or  fixing 
a  movable  kidney  which  was  not  enlarged, 
I  must  be  content  with  referring  those 
who  are  interested  in  the  subject  to  an 
interesting  paper  by  Professor  Ceccherelli, 
of  Parma,  published  in  the  'Rivista 
Clinica'  of  April  1H84,  entitled  'La 
Nefrorafia  nel  Rene  Mobile.' 

TAPPING    OF    RENAL    CYSTS 

I  have  only  3  times  tapped  renal 
cysts.  These  cases  were  remarkable,  and 
some  account  of  them  follows: 

Pjionephrosis  of  the  r/'t/ht  kichieij,  ivith 
impaction  of  two  calculi  in  the  ureter. — 
On  May  16,  1865,  I  was  called  to  see 
the  mother  of  a  patient  upon  whom  I  had 
performed  ovariotomy  successfully,  the 
daughter  telling  me  that  her  mother  had 
a  tumour  like  that  which  I  had  removed 
from  herself  I  found  the  patient  in  pain 
all  over  the  abdomen,  but  greater  on  the 
Ti"ht  side  and  in  the  right  loin ;  and 
I  felt  a  hard  tumour  between  the  right 
false  ribs  and  the  right  ilium,  reaching 
forward  to  within  an  inch  or  two  of  the 
umbilicus. 

The  patient  was  r)0  years  of  age, 
and  had  borne  5  children.  Her  last  child 
was  17  years  old.  Before  the  last  con- 
finement her  health  had  been  good.  This 
labour  was  protracted,  the  presentation 
having  been  transverse.  Ever  since,  she 
had  been  subject  at  times  to  pain  in  the 
back  and  right  loin.  It  used  to  come  on 
suddenly,  increase  in  violence,  and  pro- 
duce shivering  and  nausea.  After  6  or  8 
hours  it  would  cease.  Her  urine  at  the 
time  of  the  attacks  was  visually  thick, 
with  a  yellowish  sediment ;  at  other  times 
it  was  clear.  For  5  years  such  attacks 
recurred  pretty  regularly  every  G  weeks. 
Then,  after  a  more  active  life,  they  re- 
curred more  frequently,  scarcely  a  week 
intervening  from  one  to  another.  In  1860 
the  catamenia  ceased,  and  the  attacks 
became  milder  and  less  frequent,  and  she 
was  entirely  free  for  a  year  or  more.  In 
1862  the  pains  suddenly  recurred  with 
more  violence  than  ever.  After  great 
suffering  for  several  liours  '  a  dozen  or 
two  of  little  stones,  as  large  as  a  pin's 
head,'  were  passed  with  the  urine.  From 
that  time  to  the  present  attack  she  had 
been  quite  well.  On  May  8,  1865,  while 
out  walking,  she  stumbled  and  fell  upon 
her  abdomen.  She  was  lifted  up,  com- 
plaining of    great  abdominal  pain.     She 


got  home,  went  to  bed,  and  next  day  the 
pain  was  so  great  that  she  was  unable  to 
get  up.  During  the  next  6  days  she 
passed  a  good  deal  of  blood  in  the  urine, 
and  she  perceived,  for  the  first  time,  a 
tumour  as  large  as  a  cricket-ball  in  the 
right  side  of  the  abdomen.  On  the  15th 
the  pain,  which  had  almost  ceased,  re- 
turned suddenly  with  great  violence,  and 
I  was  sent  for.  She  was  much  relieved 
by  an  opiate  prescribed ;  and  I  made  a 
careful  examination  of  the  tumour.  It 
could  be  felt  below  the  right  false  ribs, 
but  its  margins  could  not  be  made  out 
very  distinctly.  They  appeared  to  be 
overlapped,  on  the  right  by  the  caicum,  and 
on  the  left  by  small  intestine.  Wherever 
the  tumour  could  be  distinctly  felt,  it 
gave  a  dull  note  on  moderately  strong 
percussion,  but  a  clear  one  on  deeper 
pressure  and  sharper  percussion.  By 
pressure  forwards  with  one  hand  on  the 
right  loin,  while  the  other  was  on  the 
front  of  the  tumour,  a  trace  of  fluctua- 
tion was  detected.  Pain  was  kept  in 
check  by  opiates,  and  on  May  19th  there 
was  a  prominent  point  near  the  middle 
of  the  tumour.    Fluctuation  being  distinct, 

1  inserted  a  very  fine  trocar  at  this  point 
(which  was  midway  between  the  umbilicus 
and  right  anterior  superior  spine  of  the 
ilium)  and  drew  off  between  2  and  3 
pints  of  thin  pus,  by  a  syringe  attached 
to  the  canula  by  an  air-tight  joint.  The 
urine,  before  the  tapping,  had  been  clear, 
but  the  day  after  it  was  found  by  Dr. 
De  Mussy  to  be  loaded  with  pus.  On 
the  27th,  notwithstanding  continued  escape 
of  pus  through  the  bladder,  the  tumour 
was  as  large  as  before  the  tapping.  I 
therefore  tapped  again,  and  after  removing 

2  pints  of  pus,  left  the  wound  unclosed. 
There  being  no  discharge  afr.(?r  2  days, 
I  inserted  a  larainaria  tent,  having  re- 
opened the  wound  with  a  lancet. 

A  very  free  discharge  went  on  for  the 
next  fortnight.  At  first  it  was  purulent, 
but  afterwards  it  consisted  of  clear  fluid, 
which  was  found  to  contain  urea.  The 
urine  became  clear  and  free  from  pus. 
Early  in  the  morning  of  June  20  great 
desire  was  felt  to  pass  water.  After  much 
difficulty  and  pain  a  calculus  of  uric  acid 
and  urate  of  ammonia,  as  large  as  a  broad 
bean,  and  much  of  the  same  shape,  was 
passed,  and  was  soon  followed  by  a  second 
of  .similar  dimensions.  Relief  was  im- 
mediate. On  July  1  there  was  still  a 
little  discharge,   perhaps  1    ounce  in  24< 


O^ERATI^'E   SURGERY   OF   THE   KID^'EY 


hours.  Tlie  abdomen  was  everywhere 
clear  on  percussion  ;  but  on  deep  pressure 
a  hard  painless  tumour,  as  large  as  an 
orange,  was  to  be  felt  in  the  right  loin. 
After  a  few  weeks  this  could  no  longer 
be  felt.  She  died  in  1880,  after  several 
years  of  good  health. 

This  case  is  in  many  respects  very 
instructive.  The  patient  probably  had  a 
tendency  to  deposit  uric  acid  before  her 
last  labour.  The  effects  of  that  pro- 
tracted labour  led  perhaps  to  the  train  of 
symptoms  which  ended,  for  a  time,  in 
the  passage  of  numerous  small  calculi. 
Then,  in  18G3  or  1864,  two  renal  calculi 
began  to  form,  and  set  up  chronic  pyelitis. 
The  fall  in  1865  dislodged  the  calculi, 
and  they  blocked  up  the  ureter.  The  pus 
and  urine  accumulated  behind  the  calculi 
and  distended  the  pelvis  of  the  kidney 
into  the  cavity  from  which  1  removed  the 
large  quantity  of  pus  at  the  first  tapping  ; 
and  it  was  not  till  the  calculi  passed  on 
into  the  bladder  and  left  the  ureter  free 
that  the  formation  of  pus  ceased  and  the 
artificial  opening  closed. 

Renal  cijst  tvith  calculi;  tcqyping. — 
A  single  lady,  59  years  of  age,  first  con- 
sulted me  in  June,  1865.  She  had  then 
a  tumour  which  filled  all  the  left  side  of 
the  abdomen  and  extended  upwards  under 
the  left  false  ribs.  It  had  been  observed 
for  nearly  2  years,  but  its  increase  had 
only  been  rapid  for  about  6  months. 
In  August  1866  fluctuation  was  detected 
in  the  upper  part  of  the  tumour,  and  5 
or  G  pints  of  yellowish  pyoid  fluid,  with 
mucous  flakes  floating  in  it,  were  re- 
moved by  tapping.  A  roll  of  intestine 
adhered  to  the  upper  part  of  the  tumour 
on  the  right  side.  Relief  followed  the 
tapping  for  a  time  ;  but  a  second  tapping 
was  necessar}''  in  November,  The  true 
nature  of  the  tumour  then  became 
apparent.  The  presence  of  intestine  in 
Iront  of  the  tumour,  and  the  limitation 
of  the  tumour  to  the  left  side  of  the 
abdomen,  while  the  uterus  was  freely 
movable,  were  the  chief  guides  in  diag- 
nosis, as  the  urine  was  normal,  and  there 
was  nothing  characteristic  in  the  fluid 
removed  by  tapping.  In  April  1867  the 
patient  fell  Avhen  out  walking  and  rup- 
tured the  cyst.  She  died  28  hours  after- 
wards ;  and  Dr.  Morton,  of  the  Abbey 
Road,  found  a  large  quantity  of  turbid 
fluid  in  the  peritoneal  cavity,  correspond- 
ing with  similar  fluid  found  in  a  large 
raptured  cyst  of  the  left  kidney.      The 


renal  tumour  filled  all  the  left  half  of  the 
abdominal  cavity.  Its  lower  end  dipped 
down  into  the  pelvis,  but  was  quite  free. 
Its  upper  end  adhered  to  the  spleen.  The 
ruptured  cyst  contained,  besides  the  fluid, 
a  quantity  of  very  thick  viscid  mucus, 
and  seven  calculi  of  varied  chemical 
composition.  The  largest  was  Ig  inch 
in  its  long  diameter;  the  smallest 
was  as  large  as  a  hazel-nut ;  two  Avere 
smooth ;  five  were  rough,  and  very 
irregular  in  outline.  One  calculus  Avas 
loose  in  the  cavity,  as  well  as  a  quantity 
of  lithic  acid  gravel.  The  other  calculi 
were  imbedded  in  the  pelvis  and  dilated 
calyces.  The  ureter  was  completely 
occluded,  and  no  communication  could  be 
found  Avith  the  bladder.  The  right  kidney- 
was  slightly  enlarged,  .  The  uterus  and 
its  appendages  were  healthy.  The  calculi 
are  in  the  Museum  of  the  College  of 
Surgeons. 

Eencd  cyst;  tapping. — In  1875,  a 
young  lady,  22  years  old,  was  brought  to 
me  from  Boston,  U,S..  with  a  history  and 
description  of  her  case  as  one  of  simple 
ovarian  cyst.  She  had  suffered  a  good 
deal  Avith  bladder  irritation,  Avithout  much 
injur}'  to  her  health.  I  found  a  fluctuat- 
ing tumour  about  the  size  of  a  cocoa-nut 
on  the  right  side,  betAveen  the  pelvis  and 
umbilicus.  Urine  sp.  gr.  1012,  pale, 
cloudy,  acid  and  albuminous,  Avith  granu- 
lar corpuscles,  single  and  in  groups,  vary- 
ing in  size,  some  Avith  single,  others  Avith 
several  smaller  nuclei,  and  like  pus  cor- 
puscles. 

On  Jul}'  3  I  tapped  and  dreAv  off  4 
pints  of  slightly  opalescent  fluid,  sp.  gr. 
1006,  which,  though  it  frothed  Avhen 
poured  from  one  vessel  to  another,  looked 
like  pure  water.  Reaction  alkaline,  and 
heat  caused  no  change.  The  chemical 
tests  Avere  equivocal,  and  the  microscope 
showed  nothing.  On  July  13  the  urine 
Avas  found  to  be  charged  Avith  pus,  dis- 
integrating red  blood-corpuscles,  and  an 
immense  number  of  round  and  irregular 
shaped  epithelial  cells,  undergoing  vacuo- 
lation,  and  proliferating.  These  cells 
Avere  not  bladder  epithelium,  and  it  re- 
mained doubtful  Avhether  they  Avere  from 
some  neAV  growth,  or  from  the  irritated 
surface  of  the  ureter. 

Great  temporary  relief  Avas  afforded 
by  the  tapping,  and  the  patient  Avent  to 
Edinburgh,  Avhere  she  Avas  again  tapped 
by  Dr.  Keith.  I  saw  her  in  Edinburgh 
in   August    1875,    and   left   her   in   Dr. 

0 


194 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


Keith's  charge.  After  about  G  weeks 
several  pints  of  pus  escaped  in  the  urine. 
In  October  she  returned  to  America. 
Before  long  an  abscess  in  the  loin  was 
opened.  A  fistula  remained,  and  at  the 
end  of  about  G  years  she  Avrote  to  Dr. 
Keith,  saying  she  Avas  very  well,  Aveighing 
140  pounds.  Subsequently  the  fistula 
not  closing,  it  was  injected  with  strong 
carbolic  acid.  All  sorts  of  troubles  fol- 
lowed, and  I  heard  of  her  in  the  autumn 
of  1883  as  being  quite  bed-ridden.  If 
one  had  knoAvn  10  years  ago  all  that  we 
BOW  know  of  renal  surgery,  as  soon  as 
tapping  the  cyst  had  proved  to  be  merely 
palliative,  something  more  tnan  injection 
and  drainage  would  certainly  have  been 
suggested. 

Tapping  and  draininf/  renal  cyst. — 
Towards  the  latter  end  of  1877,  not  long 
before  I  changed  my  position  of  surgeon 
to  the  Samaritan  Hospital  for  that  of 
consulting  siu-geon,  I  admitted  a  young 
countrywoman  with  2  tumours,  both 
deeply  attached  in  the  situation  of  the 
kidneys.  Fluctuation  was  quite  distinct 
in  the  right  tumour,  but  could  not  be 
made  cut  in  the  left,  Avhich  was  small. 
There  Avas  no  tenderness  in  front,  but  it 
was  marked  in  the  lumbar  region  on  the 
right  side,  Avhere  there  Avas  also  redness, 
SAvelling,  and  fluctuation.  The  right  thigh 
had  also  SAVollen  since  the  back  had 
become  bad.  She  dated  the  first  signs  of 
her  ill-health  to  Avhat  Avas  said  to  be  an 
attack  of  inflammation  of  the  kidney,  2 
years  after  her  confinement,  Avhen  she 
Avas  only  15. 

On  November  21  Itajiped  the  tumour 
in  the  right  loin,  leaving  a  tube  in  the 
cyst  for  drainage.  An  immense  quantity  of 
fluid  came  aAvay  into  the  bed,  rendering 
the  cyst  quite  flaccid.  The  next  day 
there  Avas  nearly  the  same  amount  of  dis- 
charge. Then  it  became  purulent,  and 
the  tube  was  shortened,  after  which  the 
discharge  resumed  its  serous  character. 
Urine  Avas  all  the  time  abimclantly 
secreted.  During  the  month  of  December 
the  discharge  gradually  diminished,  the 
tube  Avas  AvithdraAvn,  and  on  the  31st  I 
handed  her  over  to  INIr.  Thornton  Avith 
not  cA^en  a  stain  on  the  gauze  bandage. 
She  Avent  home  a]ipearing  to  be  A'cry  Avell 
on  Januai-y  9,  1878. 

Subscffuently,  hoAvevcr,  the  Avound 
reopened,  and  gave  exit  to  a  quantity  of 
Avliite,  glistening,  fatty  fluid,  Avith  great 
relief  to  an  attack   of  gout  in  both  feet. 


She  soon  recovered  from  this,  but  at 
the  end  of  2  years  reappeared  Avith  an 
ovarian  tumour  (right  side),  which  Mi'. 
Thornton  removed.  During  the  operation 
he  A'crified  the  diagnosis  of  the  cyst 
tapped  as  being  renal.  In  the  course  of 
couA-alescence  the  renal  cyst  refilled, 
burst,  and  healed.  Then,  at  the  end  of 
some  Aveeks,  the  left  side  had  to  be  dealt 
Avith  by  tapping  and  draining.  Again 
she  recovered,  and  again  in  15  months' 
time  Avas  discharging  fluid,  Avith  choles- 
terine,  from  the  right  side,  and  tliis  lasted 
for  14  months.  Once  more,  in  February 
1883,  she  Avas  reported  to  be  in  excellent 
health  in  all  respects.  She  has  since  mar- 
ried again,  and  is  now  (1885)  quite  Avell. 

INCISION    AND    EMPTYING    HENAL    CYST 

The  folloAving  case  of  C//stic  Degenera- 
tion of  the  IjCJI  Kidney,  which  was  mis- 
taken for  a  cyst  of  the  left  ovary,  is  not 
less  instructive  : 

On  October  10,  1866,  a  married 
woman,  43  years  of  age,  called  upon  me 
Avith  a  letter  from  Dr.  M'Donnell,  of 
Stoke  NeAvington,  containing  a  very  full 
and  accurate  histoiy  of  her  case.  She 
had  been  married  25  years,  and  had 
9  children.  Dr.  McDonnell  Avrote  as 
folloAvs :  '  In  April  1862  she  sought  my 
advice  for  a  hard  swelling  situated  in  the 
hypogastric  and  left  iliac  regions,  the  size 
of  an  infant's  head.  Examination  ex- 
ternally, and  per  vaginam,  couAdnced  me 
it  Avas  an  ovarian  tumour.  In  1854  and 
1855  a  swelling  Avas  complained  of,  and 
had  been  the  siihject  of  conversation  be- 
tween husband  and  Avife,  but  no  advice 
Avas  asked  for  at  the  time.  Aching  pain 
Avas  felt,  from  time  to  time,  in  the  tumour 
without  causing  any  alarm.  It  had  in- 
creased so  much  in  the  early  part  of 
1863  as  to  suggest  the  question  of  preg- 
nancy. In  1863  the  tumour  increased  in 
size,  extended  to  the  epigastrium,  and 
encroached  so  much  on  the  chest  as 
greatly  to  impede  the  breathing,  and  even 
prevent  her  moving  about  in  bed. 
Assisted  by  Mr.  Forman,  of  Stoke  NeAv- 
ington, on  August  4,  1866,  I  Avithdrew, 
by  tapping  in  the  linea  alba,  2  gallons 
of  dark  discoloured  fluid,  of  the  consis- 
tence of  pea-soup.  The  opening  Avas 
made  midway  betAveen  umbilicus  and 
pubcs.  Ilcr  strength  and  spirits  liavo 
much  improved,  though  the  cyst  has  re- 
filled.' 


OPERATIVE  SURGERY   OF   THE   KIDNEY 


lO: 


It  was  rather  more  than  2  months 
after  this  tapping  when  I  first  saw  the 
patient,  and  I  then  advised  her  to  come 
into  hospital  before  she  became  as  much 
distressed  as  she  had  been  before  the 
tapping.  She  was  admitted  on  December 
17,  18G6.  The  tumour  then  occupied 
the  position  shown  in  the  annexed  dia- 


gram. At  the  upper  and  central  part 
there  was  a  patch  of  crepitus,  giving  the 
feeling  of  adhering  omentum ;  and  all 
down  the  front  of  the  tumour,  about  an 
inch  to  the  left  of  the  umbilicus,  was  a 
cordlike  ridge,  which  Avas  taken  by  some 
Avho  examined  it  for  intestine,  though  it 
felt  very  like  a  large,  long,  and  thick 
Fallopian  tube.  The  measurements  were  : 
Girth  at  the  umbilical  level,  3G  inches  ; 
from  umbilicus  to  ensiform  cartilage,  9 
inches ;  to  symphysis  pubis,  7^  inches ; 
to  right  ilium,  9  inches ;  and  to  left  ilium, 
9^  inches.  There  was  some  mobility  in 
the  tumour,  both  vertically  and  laterally. 
Fluctuation  was  distinct  across  the  whole 
tumour,  in  all  directions.  The  lefc  loin 
was  dull  on  percussion,  the  right  tym- 
panitic. The  uterus  was  high,  the  os 
hard  and  fissured,  admitting  the  tip  of 
the  finger  ;  the  cervix  short.  No  part  of 
the  tumour  was  below  the  brim  of  the 
pelvis.  The  catamenia  were  expected  in 
a  few  days.  They  recurred  regularly 
every  3  weeks — lasting  5  days.  Dr. 
Jimker  examined  the  urine  and  reported 
— '  No  albumen;  deposits — urates,  mucus, 
and  epithelium.'  She  was  subject  to 
occasional  nervous  attacks,  during  which 
she  was  partially  unconscious.  She  said 
they  began  by  palpitation.  She  had  four 
while  in  hospital ;  but  they  were  regarded 
as  hysterical,  and  attracted  little  attention. 
The  catamenia  came  on,  and  ceased  on 
December  29  ;  and  on  January  3,  1867, 
chloroform  having  been  administered  by 
Dr.  Junker,  I  made  an  incision  5  inches 


long,    extending    downwards    alou"^   the 
linea  alba,  from  1  inch  below  the  umbili- 
cus.    On   opening  the  peritoneum,  I  at 
once  found  that  the  hard   roll,  or  ridge, 
observed  running  down  the  front  of  the 
tumour   was  part  of  the  transverse  and 
descending  colon,  adhering  closely  both 
to  the  cyst  and  to  the  abdominal  wall.     I 
separated   some  of  these  attachments,  in 
order  to  tap  the  cyst  safely.     On  intro- 
ducing the  trocar,  about  1.5  pints  of  fluid 
escaped.     It   had  the  appearance  of  pea- 
sonp.     When  tlie  cyst  was  empty  I  made 
some  further  separation  of  omentum  and 
intestine ;    and   wl:en   passing   my  hand 
round  the  right  side  of  the  cyst,    what 
appeared  to  be  another  cyst  gave  way, 
and  between  1  and  2  pints  of  clear  fluid 
escaped.      I   then   found   that   the   deep 
attachments  of  the  cyst  were  too  close  to 
admit  of  separation  ;  and  after  tying  3  ves- 
sels which  were  bleeding  in  the  separated 
omentum,  and  cutting  off  the  ligatures 
short,  I  closed  the  wound. 

The  patient  rallied  slowly  from  the 
chloroform,  and  complained  of  pain,  which 
was  relieved  by  an  opiate.  Two  other 
opiates  were  given  at  night — the  total 
quantity  given  amounting  to  50  minims 
of  laudanum.  Three  hours  after  operation 
a  small  quantity  of  clear  urine  was  dra^vn 
off"  by  the  catheter.  After  this  not  a  drop 
of  urine  entered  the  bladder.  At  10  p.m. 
the  temperature  was  98'4°;  pulse  116; 
respiration  28.  The  next  morning  the 
pulse  was  120,  and  very  feeble;  skin  dry  ; 
temperature  98° ;  respiration  30.  She 
was  comatose,  but  easily  roused,  and 
answered  questions  sensibly.  The  coma 
gradually  became  more  profound,  and 
she  died  30  hours  after  operation. 

On  examining  the  body  17  hours  after 
death  there  was  no  rigor  mortis.  The 
wound  had  united  well.  There  were 
about  4  pints  of  blood-red  serum,  and 
a  small  teacupful  of  blood-clot  in  the 
peritoneal  cavity.  The  right  kidney  was 
enlarged,  and  very  soft ;  the  cortical  sub- 
stance very  friable,  pale  yellow  in  colour. 
The  calyces  and  pelvis  Avere  much  dilated ; 
and  the  thin  sac  formed  by  this  dilatation 
had  given  way  longitudinally.  A  calculus, 
weighing  40  grains,  was  in  one  of  the 
calyces,  forming  a  perfect  cast  of  tlie 
calyx.  The  bladder  was  contracted  and 
empty.  The  uterus  and  ovaries  were 
healthy.  The  left  kidney  formed  the 
cystic  tumour,  which  is  described  as 
follows  by  Dr.  Junker  : 

02 


19G 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


*  The  left  kidney  formed  a  cyst  larger 
than  an  adult  head.  It  presented  one 
large  cavity,  composed  of  several  wide 
pouches,  arranged  vertically  at  one  side 
of  the  principal  cavity.  The  stroma 
which  formed  the  external  wall  was  of 
varying  thickness ;  thicker  and  stronger 
at  the  base  of  the  pouches;  thinner  and 
less  dense  around  the  main  cyst.  It  had 
a  serous  external  coat ;  at  some  places 
hypertrophied,  at  others  atrophied.  Next 
a  fibrous  structure  (fibrous  capsule  of  the 
kidney).  This  was  followed  by  Avhat 
appears  to  have  been  the  cortical  substance 
of  the  kidney,  and  from  Avhich  portions 
could  be  traced  into  the  septa  (the  former 
columnte  Bertini)  which  separated  the 
pouches  (the  expanded  calyces).  The 
main  cyst  (the  original  pelvis)  was  formed 
by  the  peritoneal  and  fibrous  capsules. 
The  medullary  portion  could  not  be  well 
distinguished  by  the  naked  eye  from  the 
thickened  lining  membrane.  Thus  the 
tumour  appears  to  be  a  good  specimen  of 
genuine  hydronephrosis,  in  which  pelvis 
and  calyces  expand  into  a  large  cavity, 
and  produce  by  pressure  atrophy  of  the 
original  structures  of  the  organ. 

'  The  peritoneal  coat  was  rough  with 
shreds  of  the  broken-down,  extensive,  and 
intimate  adhesions.  Some  of  the  neigh- 
bouring organs,  or  portions  of  them,  were 
so  intimately  connected  with  the  tumour 
that  their  separation  was  impossible,  and 
portions  had  to  be  cut  off  in  order  to 
remove  the  cyst.' 

Incision,  and  opening  renal  cyst. — 
Another  case  of  great  practical  interest 
is  that  of  a  girl  in  her  16th  year,  who  was 
sent  to  me  by  Dr.  Wardell,  of  Tnnbridge 
Wells,  on  account  of  an  abdominal  tumour. 
She  was  a  fat,  ilorid  girl,  and  apparently 
in  robust  health ;  but  her  abdomen  began 
to  enlarge  when  she  was  about  12  years 
old,  and  Avent  on  increasing,  not  attracting 
any  j^articular  notice  till  May  or  June 
1871,  when  she  was  seized  with  some 
pain  on  the  right  side.  This  lasted  only 
a  few  hours,  and  was  followed  by  swelling, 
also  on  the  right  side,  Avhich  disappeared 
after  some  days'  rest,  the  general  enlarge- 
ment remaining.  Dr.  Wardell  first  wrote 
to  me  about  her  in  October  IHJI.  A 
month  later  he  wrote  that  the  tumour  was 
enlarging,  and  she  was  admitted  into  the 
Samaritan  Hospital  early  in  December. 
On  December  15  the  girth  at  the  umbi- 
lical level  Avas  35  inches,  distance  from 
sternum  to  pubes  15  inches,  and  from  one 


ilium  to  the  other,  across  the  front  of  the 
abdomen,  15^  inches.  Fluctuation  was 
distinct  all  over  the  lower  part  of  the  ab- 
domen, and  the  movement  of  a  cyst  was 
distinctly  visible  between  the  umbilicus 
and  sternum — rising  and  sinking  with  the 
respiratory  movements — the  upper  border 
of  the  cyst  being  about  half  way  between 
the  sternum  and  the  umbilicus.  On  both 
sides  of  the  abdomen  the  sound  was  dull 
on  percussion ;  so  it  was  from  the  pubes 
to  within  2  inches  of  the  umbilicus.  From 
thence  to  the  upper  border  of  the  cyst  in 
the  centre  it  was  resonant  or  tympanitic, 
and  on  pressure  with  the  fingers  the  pecu- 
liar gurgling  and  contraction  of  intestine 
could  be  felt.  It  was  quite  clear,  there- 
fore, that  we  had  intestine  adhering  in 
front  to  the  upper  part  of  the  cyst.  Both 
loins  and  flanks  were  clear  on  percussion, 
the  right  more  distinctly  so  than  the  left. 
The  uterus  was  normal  in  size  and  situa- 
tion. On  the  right  side  of  the  vagina  a 
soft  fluctuating  mass  (the  lower  part  of 
the  cyst)  could  be  felt  just  above  the  brim 
of  the  pelvis.  The  catamenia  appeared 
when  she  was  14,  and  continued  regular 
for  4  months,  then  ceased  for  4  months, 
and  since  then  have  been  regular  but  ex- 
cessive, lasting  a  week.  There  was  some 
irritability  of  bladder.  Owing  to  a  mis- 
take, the  urine  was  not  examined. 

The  girl  was  kept  in  hospital,  and  on 
January  23,  1872,  the  girth  had  increased 
to  37  inches,  and  each  of  the  other 
measurements  shoAved  an  increase  of  about 
an  inch.  The  presence  of  intestine  in 
front  of  the  cy^t  led  to  the  suspicion  of 
hydronephrosis ;  but  the  resonance  of  both 
loins  and  the  fact  that  the  cyst  could  be 
felt  by  the  vagina  on  the  right  side,  almost 
negatived  this  suspicion,  and  it  appeared 
more  probable  that  we  had  to  deal  Avith  a 
multilocular  ovarian  cyst,  to  which  intes- 
tine adhered  in  front.  I  made  an  explora- 
tory incision  on  January  24,  and  at  once 
came  upon  the  caecum,  its  appendix,  and 
the  ascending  colon,  Avhich  had  been 
pushed  upAvards  and  across  the  median 
line  by  the  cyst,  which  Avas  behind  it.  I 
saw  at  once  1  had  to  deal  with  a  hj'dro- 
nephrosis ;  so,  pushing  aside  the  intestine, 
I  tapped  the  cyst.  Twelve  pints  of  fluid 
escaped  through  the  canula,  and  I  then 
found  that  the  uterus  and  both  ovaries 
Avere  healthy.  When  the  cyst  Avas  empty 
I  fixed  the  opening  in  its  Avail  to  the  ab- 
dominal Avail  by  a  harelip-pin,  and  then 
closed  the  wounds  by  sutures.     A  small 


OPERATIVE   SURGERY   OF   THE   KIDNEY 


107 


cyst  in  each  broad  ligament  I  felt,  but  did 
not  disturb. 

The  fluid  removed  from  the  cyst  was 
clear,  light  yellow  in  colour,  Avith  a  faint 
lirinous  odour,  acid  reaction,  and  specific 
gravity  of  lOOG.  On  standing  a  few  floc- 
culent  clouds  formed  and  some  red  blood- 
corpuscles  were  deposited.  On  careful 
chemical  examination,  urea,  urates,  and 
chlorides  were  found  in  about  the  normal 
proportions  of  healthy  urine.  There  were 
traces  of  uric  acid.  A  very  small  amount 
of  albumen  and  phosphates,  but  no  traces 
of  sugar  co\ild  be  detected.  On  micro- 
scopic examination  of  the  deposit  large 
numbers  of  red  blood-corpuscles  were 
seen,  a  few  pus  cells,  some  squamous 
epithelial  cells  and  granular  cells,  but 
neither  tube-casts  nor  crystals. 

The  fever  which  followed  the  opera- 
tion and  caused  her  death  on  the  4th 
day  was  so  remarkable  that  I  may  refer 
those  interested  in  the  subject  to  a  lecture 
on  the  case,  v/hich  was  published  in  April 
1<S72,  in  the  *  Medical  Times  and  Gazette.' 

KEPHROTOMY 

Nephrotomy  ;  removal  of  sarcoma  from 
interior  of  i^enal  cyst. — In  May  1879  a 
Greek  lady  came  to  me  from  Dr.  White- 
head, of  Manchester,  supposed  to  be  suf- 
fering from  a  solid  movable  tumour  of 
the  right  ovary,  sufficiently  large  to  call 
for  extirpation.  Dr.  Whitehead  had  seen 
her  several  times  between  18G8  and  1871 
on  account  of  dysmenorrhosa  and  several 
early  abortions.  He  did  not  see  her  be- 
tween 1871  and  1877,  when  she  went  to 
him  on  account  of  abdominal  enlargement ; 
but  he  could  not  detect  any  tumour.  Her 
next  visit  was  in  May  1879,  and  then  he 
found  '  a  large,  solid  substance,  non-fluc- 
tuant, on  the  right  side,  somewhat  diffused, 
extending  towards  the  hepatic  region.  It 
had  not  the  iisuaily  defined  limits  of  an 
ovarian  tumour,  yet,  in  the  absence  of  the 
great  suffering  commonly  met  with  in 
aggraA^ated  kidney  disease,  and  the  urine 
being  normal,  and  as  a  perceptible  im- 
pingement of  the  tumour  was  felt  against 
the  left  hand  on  tilting  the  uterus  up  Avith 
the  right,  I  Avas  led  to  sujipose  its  nature 
to  be  ovarian.' 

In  1881  and  1882  I  saAV  this  lady  oc- 
casionally in  consultation  Avith  Sir  W. 
Jenner.  We  both  at  first  believed  that  the 
tumour  Avas  one  of  the  right  kidney.  But 
as  it  became  more  fluctuant  and  increased 


in  size,  and  the  urine  proved  to  be  normal 
upon  careful  and  repeated  examination, 
and  the  general  health  was  beginning  to 
suffer,  I  made  an  exploratory  incision  in 
1 882,  assisted  by  Dr.  Griffith,  of  Camber- 
well,  and  Mr.  Meredith,  Dr.  Day  admini- 
stering methylene.  It  Avas  at  once  evi- 
dent that  the  tumour  Avas  renal,  but  as  it 
appeared  to  be  cystic  I  tapped  it.  No 
fluid  escaped,  but  some  soft  brainlike 
substance.  On  enlarging  the  trocar  open- 
ing, several  pounds  of  this  substance,  in 
soft  masses,  came  aAvay,  and  Avith  it  a  good 
deal  of  blood.  By  passing  my  hand  into 
a  cystlike  cavity  I  Avas  able  to  press  and 
scrape  aAvay  a  quantity  of  soft  granular 
substance,  portions  of  a  groAvth  loosely 
adherent  to  the  inner  surface  of  the  cavity, 
very  much  like  the  endogenous  sprouts  of 
a  proliferating  cyst.  The  cavity  was  evi- 
dently the  dilated  pelvis  of  the  kidney, 
the  cyst  its  cortical  layer,  expanded  and 
covered  by  peritoneum,  which  it  had 
pushed  forAvard.  The  cavity  Avas  only- 
opened  enough  for  me  to  pass  in  my  hand, 
and  by  carefully  holding  the  edges  of  the 
opening  forAvard,  none  of  the  morbid 
material  or  blood  entered  the  peritoneal 
cavity.  There  Avas  such  free  bleeding  from 
the  inner  Avails  of  the  cavity  that  I  stuffed 
it  full  of  carbolised  sponges,  and  had  some 
pressure  kept  upon  these  Avhile  I  was  pass- 
ing the  sutures.  These  included  the  edges 
of  the  opening  in  the  renal  cyst,  as  well  as 
the  Avhole  thickness  of  the  abdominal  wall. 
I  then  gradually  removed  the  sponges, 
pressure  being  all  the  Avhile  kept  up.  I 
thought  of  tying  the  renal  vessels  and  re- 
moving the  kidney.  I  also  thought  of 
leaving  a  drainage-tube  in  the  cyst,  for 
the  oozing  of  blood  was  not  quite  stopped 
Avhen  I  took  out  the  last  sponge.  The 
patient  Avas  so  exhausted  that  I  Avas  sure 
she  could  not  survive  nephrectomy.  If  I 
had  left  a  tube  in  I  feared  the  bleeding 
AYOuld  go  on ;  so  I  closed  the  wound  and 
made  firm  pressure  by  pads  and  a  bandage. 
She  remained  in  a  state  of  profound  col- 
lapse for  5  or  6  hours,  pulse  almost, 
sometimes  quite,  imperceptible ;  she  was 
cold  and  sometimes  quite  unconscious. 
Ether  Avas  injected  subcutaneously, 
brandy  fi:eely  given  by  the  mouth,  and 
beef-tea  and  milk  by  the  rectum.  Dr. 
Griffith  stayed  Avith  her  all  night,  and 
to  his  assiduous  care  for  several  foUoAving 
days  I  attribute  her  gradual  and  complete 
recovery.  There  has  never  been  any  re- 
appearance of  the  renal  tumour  since  the 


UTERINE   AND   OTHER   ABDOMINAL   TmiOUES 


operation,  the  xirine  has  been  almost  al-  i 
■ways  normal,  and  I  saw  her  near  the  end 
of  I8<s4  in  excellent  health.     The  masses 
removed  "weighed  more  than  9  povmds,  and 
Mr.  Meredith  reported  to  me  that,  on  mi-  \ 
croscopical  examination  of  different  speci- 
mens of  the  material  from  the  cyst,  he  i 
found  that  '  the  growth  Avas  undoubtedly  a  , 
spindle- celled  sarcoma,  apparently  under-  i 
going  caseous  changes.     The  spindle  cells 
were  large  and  very  distinctly  nucleated.' 

XEriiEECTOMY 

Enlarrjed  cancerous  kidney  ;  excision. 
On  December  9,  1882,  in  consultation 
with  i\Ir.  Hewer,  of  Highbury,  I  saw  a 
Grerman  gentleman,  aged  58,  who  was  suf- 
fering from  the  effects  of  repeated  attacks 
of  hematuria,  supposed  to  depend  upon 
an  enlarged  left  kidney.  The  amount  of 
blood  lost  had  seriously  affected  the  general 
health,  and  on  different  occasions  it  had 
been  with  difficulty  that  the  bladder  had 
been  cleared  from  clots.  There  was  no 
evidence  of  any  disease  of  the  bladder  nor 
of  the  right  kidney.  The  left  kidney 
appeared  to  be  about  4  inches  in  breadth 
and  6  inches  from  above  downwards ; 
extending  from  the  iliac  fossa  upwards 
imder  the  left  false  ribs,  and  centrally 
nearly  to  the  umbilicus.  It  was  slightly 
mobile,  and  could  be  pushed  to  the  right  a 
little  beyond  the  umbilicus.  Feeling  that 
the  surgical  difficulties  in  removing  the 
kidney  would  not  be  great,  and  that  the 
patient  was  not  likely  to  live  long  if  it 
were  not  removed,  I  advised  early  opera- 
tion, and  was  supported  by  INIr.  Hewer. 

The  patient  took  time  to  consider  the 
cjuestion,  and  consulted  his  old  friend. 
Dr.  Herman  Weber,  who  informed  me 
that  in  December  1880  he  had  observed 
the  movable  tumour,  which  had  first  been 
noticed  by  the  patient  himself  a  year 
before  this  visit. 

'In  August,  ISS],  Mr.  K was  at 

Margate,  and  one  day  the  urine  Avas 
bloody.  On  the  following  day  he  came 
up  to  me,  when  I  fovind  the  urine  quite 
free  from  blood  and  albumen,  jierfectly 
clear,  and  normal.  The  first  severe  bleed- 
ing occurred  in  May  1882,  when  I  had 
not  .seeii  him  for  8  months.  It  ceased 
completely  under  the  administration,  by 
i\Ir.  Hewer,  of  turpentine  in  ca2:)sules.  In 
July  and  August  he  went  to  Germany, 
and  was  so  well  that  he  could  climb 
moderate  mountains.    By  that  time  I  had 


attributed  the  tumour  to  the  kidney,  and 
feared  that  probably  it  was  malignant.' 

Three   days  after  my  first  visit  ]\Ir. 
Hewer   wrote    to    me :     '  December    12, 
1882,   the  patient   is  losing  more  blood 
and  consents  to  the  operation,  which,  I 
think,  should  be  done  with  as  little  delay 
as  possible.'     Proposing   to    operate   the 
next  afternoon,   Mr.   HeAver   telegraphed 
to  me,  '  Patient  not  so  well,  please  make 
operation,  if  possible,  to-morrow  morning.' 
Accordingly,  at  9  o'clock  on  the  morning 
of  December  13 — Dr.  Herman  Weber  and 
Mr.  Hewer  being  present — Dr.  Day  ad- 
ministered methylene,  and  I  was  assisted 
by  Mr.  Meredith  and  Mr.  Hewer's  son, 
house-surgeon     of     St.     Bartholomew's. 
Phenol    spray  Avas   used   and   the   usual 
antiseptic    precautions  were    strictly  ob- 
served.     I  made  an  incision  parallel  with, 
and  about  2  inches  to  the  left  of  the  linea 
alba,  extending  from  about  3  inches  above 
to  3  or  4  inches  beloAv  the  IcA-el  of  the 
umbilicus.     I  meant  to  carry  the  incision 
along  the  outer  border  of  the  left  rectus, 
but  the  muscle  Avas  spread  out  and  some 
of  its  fibres  Avere  divided  or  separated  all 
along  the  incision.     SeA'^eral  small  arteries 
were  tied,  and  the  peritoneal  coat  of  the 
anterior  abdominal  Avail  Avas  divided   to 
the  extent  of   6   inches.     The  intestines 
Avere  pushed  aside,  kept  back  by  carboliscd 
sponges,  and  the   peritoneal   covering  of 
the  kidney  Avas  diAdded  to  the  same  extent 
as  the   incision   in    the    abdominal   Avail. 
Several  large  veins,  Avhich  Avere  divided 
Avith  the  peritoneal  covering  of  the  kidney, 
Avere  tied.    The  kidney  Avas  then  separated 
from  its  loose  attachments  and  draAvn  out. 
The  ureter  AA-as  first  temporarily  secured 
by  tAvo  pressure-forceps  and  divided  be- 
tween them.     I  meant  to  have  tied  the 
renal  artery  and  vein  before  separating 
the  kidney,  but  I  could  not  feel  the  artery. 
I   therefore    compressed    the    connecting 
tissue  Avith  forceps,  cut  aAvay  the  kidney, 
then  transfixed  with  a  double  silk  ligature 
behiiid  the  forceps,  and  tied  in  2  parts. 
Loose  portions  of  tlie  peritoneal  covering 
of  the  kidney  Avere  cut  aAvay  and  several 
ligatures  Avere   applied   to   small   A'cssels. 
The  incision  in  the  abdominal  Avail  Avas 
united  by  silk  sutures. 

Not  much  l)lood  Avas  lost  during  the 
operation,  although  it  occupied  nearly  1^ 
hour  from  the  commencement  of  inhala- 
tion until  the  patient  Avas  in  bed.  Much 
time  was  lost  in  tying  small  vessels  in  the 
abdominal  wall  before  opening  the  peri- 


OPEILVTIVE   SURGEllY   OF   THE   KIDNEY 


199 


toneum,  and  in  securing  A'cssels  in  tho 
divided  coverings  of  tiie  kidney ;  and, 
during  the  closing  ol'  tlie  wound,  tliere 
was  unusual  difficulty  in  keeping  back 
the  intestines  free  from  the  sutures. 

The  kidney  is  now  in  the  Museum  of 
the  Koyal  Coliege  of  Surgeons,  and  Mr. 
Eve's  report  on  the  specimen  is  as  follows: 

'The  kidney  is  G.V  inches  long  and  4 
wide.  Its  surface  is  laigely  nodulated  or 
bossed,  but  the  disease  had  not  penetrated 
the  capsule.  The  section  of  the  tumour 
is  white,  soft,  and  marked  by  bands  of 
fibrous  tissue,  which  give  it  a  lobuluted 
appearance.  Portions  of  unaffected  kidney 
substance  are  situated  at  the  upper  and 
back  parts  of  the  section.  Neither  the 
ureter  nor  pelvis  was  compressed.  Micro- 
scopically the  morbid  growth  was  a  soft 
cancer,  consisting  of  alveoli  filled  with 
small  spheroidal  epithelium.' 

For  3  days  after  the  operation  the 
patient  Avent  on  so  Avell  that  I  was  hopeful 
of  I'ecovery.  He  suffered  very  little  from 
pain  or  sickness,  but  the  urine  never  be- 
came free  from  blood.  On  the  4th  day 
the  temperature  rose  to  102°,  and  the 
pulse  became  rapid  and  feeble.  He  was 
much  worse  at  night,  and  died  on  the 
morning  of  the  5th  day.  The  temperature 
just  before  death  was  103°,  and  the  last 
iirine  passed  contained  blood.  No  post- 
mortem examination  of  the  body  was  per- 
mitted. This  I  very  much  regret,  as  I 
cannot  explain  the  continuance  of  blood 
in  the  urine  in  the  absence  of  any  proof 
of  disease  of  the  right  kidney  or  of  the 
bladder,  nor  can  I  offer  any  reason  of  the 
precise  cause  of  death.  There  Avas  no 
evidence  of  more  than  slight  peritonitis, 
nor  of  septicemia.  The  chances  of  suc- 
cess would  have  been  much  greater  if  the 
ojjeration  had  been  done  6  months  earlier. 
If  I  should  again  be  called  upon  to 
excise  a  kidney,  I  shall  be  more  careful 
in  bringing  together  not  only  the  divided 
peritoneum  of  the  anterior  abdominal 
wall,  but  also  the  divided  peritoneal 
covering  of  the  kidney.  In  this  case  I 
was  content  Avith  letting  the  tAVO  edges 
fall  together;  and  it  is  probable  that 
blood  or  serum,  exuding  from  the  tissues 
behind  the  peritoneum,  passed  into  the 
peritoneal  cavity,  or  that  some  portion  of 
intestine  became  adherent  there.  Both 
these  evils  would  be  prevented  by  a  fcAv 
sutures.  I  had  not  seen  this  detail  in  the 
operative  procedure  described  in  cases  of 
nephrectomy  previously  recorded ;  and  I 


have  not  no  ticed  any  report  of  its  having 
been  tried  in  more  recent  cases.  In  the 
discussion  Avhich  folloAved  the  reading  of 
the  above  slightly  abbreviated  account  of 
the  case  at  the  Medico-Chirurgical  Society, 
it  Avas  argued  that  this  Avould  not  be  ad- 
visable; that  it  Avould  be  better  that 
blood  and  serum  should  pass  into  the 
peritoneal  cavity,  and  be  absorbed,  than 
retained  behind  the  peritoneum  in  the 
loin.  Indeed  it  Avas  suggested  that  a 
counter  opening  should  ahvays  be  made 
in  the  loin  Avhen  nephrectomy  Avas  per- 
formed by  the  abdominal  incision,  and 
that  one  of  the  chief  advantages  of  the 
lumbar  incision  was  the  greater  facility  it 
afforded  for  drainage. 

In  the  papers  and  discussions  at  the 
International  Medical  Congress  in  London, 
in  1881,  on  nephrotomy  and  nephrectomy, 
by  Czerny,  Langenbuch,  Martin,  Baker, 
Lucas,  and  BarAvell,  the  situation  of  the 
abdominal  incision  and  the  relative  ad- 
A-antages  of  the  abdominal  and  lumbar 
incision  Avere  ably  entered  into  ;  and  quite 
recently  the  discus.sion  has  been  renewed 
in  the  Royal  Medico-Chirurgical  Society, 
Avhen  Mr.  Thornton's  proposal  to  tie  the 
ureter,  and  to  fix  it  in  the  abdominal 
wound,  Avas  both  supported  and  objected 
to.  My  own  feeling  is  that  in  most  cases 
of  nephrotomy  for  renal  calculus,  or  of 
nephrectomy,  Avhen  the  kidney  to  be 
removed  is  not  A^ery  large,  the  lum- 
bar incision  should  generally  be  pre- 
ferred ;  whereas  the  abdominal  incision 
is  ratlier  to  be  chosen  whenever  the 
kidney  is  much  more  than  double  the 
normal  size.  And,  Avhenever  the  ab- 
dominal incision  is  chosen,  that  of  Lan- 
genbuch has  some  advantages  over  an 
incision  in  the  middle  line.  It  may  be 
made  alono-  the  outer  border  of  the  right 
or  left  rectus,  according  to  Avhich  kidney 
it  is  intended  to  remove.  I  also  think 
Mr.  Thornton  has  made  out  a  fairly  good 
case  in  favour  of  his  practice  of  fixing  the 
bladder  end  of  the  ureter  outside  the 
abdominal  incision.  He  ties  it  Avith 
strong  silk,  and  cuts  it  off  so  as  to  leaA'e 
only  just  enough  stump  to  pass  a  pin 
through  and  keep  it  from  slipping  into 
the  Avound.  He  cleans  this  stump  Avith 
iodine,  and  packs  it  round  Avith  a  little 
cotton  moistened  Avith  tincture  of  iodine, 
until  the  peritoneum  is  Avell  sealed.  But 
it  is  quite  certain  that  Ave  require  a  larger 
number  of  cases,  fully  and  accurately 
reported,  before  these  and  other  practical 


200 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


details  in  the  operative  surgery  of  the 
kidney  can  be  considered  as  settled. 

Solid  pei'i-7-enal  tumours. — Since  the 
case  of  nephrectomy  just  recorded,  I  have 
removed  2  very  large  solid  tumours 
formed,  in  the  same  patient,  around  the 
right  and  the  lelt  kidney.  One  tumour 
"weighed  IGt?  pounds,  the  other  14?y  pounds, 
and  part  of  the  lelt  kidney  was  attached 
to  the  tumour  of  that  side.  This  portion 
of  kidney,  with  part  of  the  tumour  at- 
tached to  it,  is  preserved  in  the  Museum 
of  the  College  of  Surgeons.  I  removed 
the  tumours  in  November  1883,  and  the 
following  report  upon  them,  by  Mr.  Eve, 
Avas  published  in  the  '  British  Medical 
Journal,'  April  19,  1884: 

'  The  portion  of  kidney  on  the  tumour 
comprises  more  than  one-third  oi;  the 
lower  end  of  the  organ.  A  calyx  and 
papilla  may  be  seen  upon  the  torn  sur- 
face ;  they  afford  conclusive  evidence  that 
the  pelvis  was  opened.  Within  the  calyx 
is  a  small  mass  of  fat.  A  section  of  the 
kidney  has  a  normal  appearance.  Sur- 
rounding the  surface  of  tlu;  kidney  is  a 
tolerably  firm,  greasy,  pale  yellowish 
Avhite  substance,  evidently  consisting,  in 
great  part,  of  adipose  and  fibrous  tissues. 
It  is  in  close  contact  with  the  capsule  of 
the  kidney,  but  is  only  adherent  to  it 
over  a  surface  about  ^  an  inch  in  length. 
The  capsule  can  be  easily  separated  from 
the  kidney  at  this  point,  leaving  the  sub- 
jacent parenchyma  perfectly  smooth. 

'  The  portion  of  the  tumour  from  the 
opposite  side  was  slightly  more  fibrous  in 
texture,  but  otherwise  similar  in  its  naked- 
eye  characters. 

'  In  minute  structure,  both  tumours 
consisted  chiefly  of  adipose  tissue.  The 
fat-cells  were  large,  and  closely  approxi- 
mated. There  were  also  many  large 
tracts  and  bands  of  fibrillar  connective 
tissue,  consisting  of  a  close  interlacement 
of  delicate  fibrils,  which  give  it  somewhat 
the  appearance  of  mucous  connective 
tissue,  but  stellate  cells  Avere  absent.  The 
blood-vessels  were  large  and  numerous, 
and  around  them  AVere  masses  of  small, 
round,  so-called  "  indifferent"  cells,  Avhich 
could  be  traced  through  transitions,  by 
elongation,  to  the  formation  of  fibres. 

'  1'lie  formation  of  fat  Avas  evidently 
secondary  to  the  growth  of  fibrous  tissue, 
tlie  advance  of  the  fiit-cells  into  it  being 
apparent ;  Avliile  the  various  stages  in  the 
transformation  of  the  fixed  connective 
tissue   corpuscles  into  fat-cells  were  dis- 


tinctly seen.  Sections,  cut  through  the 
point  Avhere  the  tumour  was  adherent  to 
the  kidney,  showed  that  numerous  parallel 
fasciculi  of  fibrous  tissue  intervened  be- 
tween the  kidney-substance  (which  Avas 
healthy)  and  the  tumour. 

'  The  anatomical  relations  of  the 
tumours  to  the  kindeys,  and  the  micro- 
scopic examination,  support  the  view  that 
the  tumours  originated  neither  in  the 
pelvis  nor  capsule  of  the  kidney,  but  in 
the  circumrenal  connective  tissue. 

'  Histologically,  they  were  fibro-lipo- 
mata,  and  no  grounds  exist  for  believing 
them  to  be  in  any  part  sarcomatous,  since 
the  young  cell-element  exhibited  a  distinct 
tendency  to  form  mature  tissues,  either 
fibrous  or  fatty.  A  complete  immimity 
from  further  disease  may,  therefore,  be 
anticipated,  provided  that  the  growths 
Avere  completely  remoA'ed.' 

The  lady  Avas  48  years  of  age  ;  Avas 
married  Avhen  21  ;  had  never  been  preg- 
nant ;  had  begun  to  suffer  from  abdominal 
trouble  in  1874;  and  in  1878  Avas  suffi- 
ciently large  for  pregnancy  to  be  sus- 
pected. The  enlargement  had  gradually 
increased.  Ever  since  1881,  owing  to 
prolapsus  of  the  uterus,  a  ring-pessary  had 
been  worn  until  the  day  of  operation,  and 
numbness  and  stiffness  of  the  right  leg 
had  been  troublesome.  The  catamenia 
had  been  regular,  and  the  urine  Avas 
always  normal  Avhen  examined. 

I  had  been  very  doubtful  as  to  the 
precise  character  and  origin  of  the 
tumours  V)efore  operation,  simply  saying 
tliat  there  Avere  2  solid  tumours,  so  moA^- 
able  that  I  did  not  think  there  could  be 
any  unusual  difficulty  in  their  removal. 
On  making  tlie  incision  usual  in  ovario- 
tomy, a  growth  resembling  an  ordinary 
fatty  tumour  Avas  seen  to  be  covered  by 
layers  of  loose  serous  membrane,  just  as 
in  tvmiours  covered  by  the  broad  liga- 
ments of  the  uterus.  This  membranous 
capsule  Avas  divided,  and  the  tumour  easily 
shelled  out  from  a  large  deep  cavity  in 
the  left  side  of  the  pelvis  and  left  loin. 
Attached  to  the  deepest  part  of  the 
tumour  Avas  a  piece  of  dark  red  ti.ssue, 
which  I  at  first  thought  Avas  a  part  of  i\vi 
spleen  ;  but  Avhich  afterwards  j^roved  to 
be  about  a  third  of  the  left  kidney.  The 
remaining  portion  of  the  kidney  and  the 
ureter  Avere  then  seen  at  the  bottom  of 
the  capsule.  There  was  very  little  bleed- 
ing. The  capsular  cavity  was  carefully 
sponged,  and    the    edges  of  the   divided 


OPEKATIVE  SURGERY   OF  THE   KIDNEY 


201 


capsule  Averc  placed  in  apposition,  but  no 
sutures  were  used. 

Another  large  tumour  was  then  found 
similarly  situated  on  the  right  side,  and 
was  removed  in  the  same  way  ;  but  the 
right  kidney  was  neither  injured  nor  seen. 
The  only  other  difFerence  in  the  proceed- 
ing on  the  two  sides  was,  that  the  ascending 
colon  led  to  no  difficulty  ;  while,  on  the 
left  side,  the  descending  colon  was  attached 
to  the  tumour  anteriorly,  and  was  pushed 
aside  after  dividing  the  serous  capsule  of 
the  tumour.  There  Avas  not  much  Ijlood 
lost,  only  a  few  small  vessels  requiring 
ligature. 

The  patient  recovered  quite  as  well  as 
after  an  ordinary  ovariotomy.  In  quantify 
and  appearance,  the  urine  was  quite  nor- 
mal. Dr.  Hilder  once  or  twice  found 
some  small  clots  of  blood  in  tlie  deposit, 
but,  he  said,  '  none  as  large  as  a  pin's 
head.'  She  remained  in  good  health  ibr 
several  months,  but  towards  the  end  of 
1884  I  heard  from  Dr.  Ilabershon  that 
he  was  attending  her  on  account  of  con- 
siderable enlargement  of  the  liver. 

Addressing  the  Midland  IMedical  So- 
ciety last  November,  1  made  the  follow- 


ing remarks  upon  the  surgical  IreatmeDt 
of  renal  and  peri-renal  tumours  : 

'  Nephrotomy,  nephrolithotomy,  pyelo 
lithotomy,  and  nephrectomy,  terms  hardly 
entering  into  surgical  literature  twenty 
years  ago,  define  operations  which  are 
now  performed  in  increasing  numbers, 
and,  especially  to  the  physiologist,  with  a 
wonderful  success.  My  colleague,  Know.s- 
ley  Thornton,  can  boast  of  10  nephrec- 
tomies, all  by  abdominal  section,  as  well 
as  4  nephrotomies  and  3  nephrolitho- 
tomies— the  whole  17  cases  successful. 
These  cases,  and  7  successful  cases  of 
pyelolithotomy  out  of  8,  as  lately  re- 
corded by  Anderson,  can  only  be  the 
efl'ect  of  rigidly  abiding  by  the  observance 
of  what  we  now  know  to  be  the  rule  and 
criterion  of  good  work.  So  also  Avitli  a 
variety  of  solid  and  semi-solid  abdominal 
tumours,  originating  in  the  pelvic  cellular 
tissue,  or  in  the  peri-renal  fat,  or  in  the 
mesentery,  the  appendices  epiploicas,  the 
omentum,  or  the  abdominal  wall,  extir- 
pation is  effected  with  a  loss  of  life  so 
small  as  would  have  been  almost  in- 
credible a  few  vears  a2;o.' 


ABSCESS   AKD    IIYDATIDS- 


CHAPTER   V 
LIVER   ANB    GALL-BLABBER 

—DISTENDED    GALL-BLADDER GALL-STONES — CIIOLECYSTOTOMY 

AND    CHOLECYSTECTOMY 


What  has  been  said  of  peritoneal  surgery 
in  relation  to  the  spleen  and  the  kidneys 
may  appear  at  first  sight  to  require  some 
modification  when  we  pass  on  to  the  liver 
and  gall-bladder.  But  it  must  be  re- 
membered that  it  used  to  be  considered 
essential  to  the  success  of  any  surgical 
treatment  of  abscess  or  cysts  of  the  liver, 
of  so-called  dropsy  of  the  gall-bladder, 
and  of  the  removal  of  gall-stones,  that 
the  peritoneal  cavity  should  be  closed  by 
adhesions  between  the  visceral  and  pari- 
etal peritoneum,  before  any  opening  into 
liver  or  gall-bladder  Avas  made.  Opening 
the  peritoneum  Avhen  non- adherent,  as 
the  first  step  of  operative  treatment,  is 
one  of  the  most  recent  advances  in  ab- 
dominal surgery.  Thudichum  and  Hand- 
field  Jones  had  stimulated  the  ambition 
of  their  surgical  brethren  ;   but  it  Avas  not 


until  the  example  of  Marion  Sims,  and 
the  attention  excited  by  the  very  remark- 
able paper  Avhich  he  published  in  the 
'  British  Medical  Journal '  in  June  1878, 
that  the  present  generation  of  siirgeons 
entered  upon  the  path  which  he  opened 
for  us.  It  is  true  that  Sims  had  been 
preceded,  in  1867,  by  another  American 
surgeon,  Bobbs,  Avho,  after  opening  the 
gall-bladder  and  removing  some  50  stones, 
closed  the  opening  by  stitches  and  did  not 
attach  it  to  the  abdominal  Avail.  The 
patient,  a  woman  30  years  old,  recovered. 
Sims  does  not  seem  to  have  read  or  heard 
of  a  A'ery  remarkable  paper,  oititled  '  On 
Tumours  formed  by  Bile  retained  in  the 
Gail-Bladder,'  Avritten  150  years  ago  (to 
which  attention  Avas  draAvn  in  1879  by 
Mr.  Hulke),  communicated  by  Petit  to 
the  French  Royal  Academy  of  Surgery  in 


20: 


UTERINE   AND   OTHER   ABD03IIXAL   TUMOURS 


1733,  and  published,  in  1743,  in  the  first 
volume  of  the  INIemoirs  of  the  Academy. 
In  this  paper  Petit  records  2  cases  ob- 
served 25  and  28  years  before,  where  con- 
siderable tumours  in  the  region  of  the  liver 
were  opened  in  the  belief  that  one  was  a 
cyst  and  the  other  an  abscess,  both  proving 
to  be  the  distended  gall-bladder,  and  death 
following  escape  of  bile  into  the  peritoneal 
cavity.  He  relates  a  third  case  where  he 
was  about  to  open  a  similar  tumour,  when 
it  disappeared,  and  a  large  quantity  of 
bile  soon  afterwards  passed  Avith  purging. 
In  a  4th  case,  a  supposed  abscess  Avas 
opened,  and  a  biliary  fistula  was  the 
result,  through  which  a  gall-stone  was 
removed  7  or  8  months  afterwards.  In 
another  j^^tient  a  considerable  tumour 
disappeared  after  the  vomiting  of  3  pints 
of  very  green  bilious  iluid.  Petit  wisely 
says :  '  In  such  difficult  cases  mistakes 
are  not  faults  when  one  has  the  courage 
to  publish  them  ;  but  they  become  crimes 
when  pride  leads  to  concealment.'  After 
a  careful  description  of  the  mode  of  dis- 
tinguishing between  cases  of  abscess  of 
the  liver  and  distended  gall-bladder,  Petit 
says  that  in  some  cases  abscess,  retention, 
and  gall-stones  are  all  observed  together. 
He  then  traces  the  parallel  between  bile 
retained  in  the  gall-bladder  with  gall- 
stones, and  retention  of  urine  with  urinary 
calculi — showing  that,  as  the  latter  occa- 
sionally pass  by  the  urethra,  the  former 
pass  the  duct  into  the  intestine ;  that 
when  retained  in  the  gall-bladder  they 
may  be  numerous  and  of  large  size,  and 
in  thin  patients  distinctly  felt  and  heard  ; 
and  when  they  occlude  a  duct  may  do 
as  much  harm  as  a  stone  blocking  a 
ureter  or  the  urethra.  He  then  shows 
that  the  danger  of  opening  a  distended 
gall-bladder  which  is  not  adherent  to  the 
abdominal  wall,  is  not  to  be  feared  when 
adhesions  have  formed,  and  that  gall- 
stones may  be  removed  through  a  biliary 
fistulous  opening.  Tie  relates  a  case 
where,  7  years  after  recovery  f?-om  severe 
symptoms  of  distended  gall-bladder,  it 
was  foTuid  that  adhesions  and  communica- 
tion with  the  colon  had  been  completed 
by  nature ;  and  he  says  that  when  adhe- 
sions have  formed,  not  only  may  a  gall- 
bladder be  opened  and  a  fistula  saiely 
formed,  but  '  surgery  may  be  enriched 
by  another  operation  ;  I  mean  the  extrac- 
tion of  stones  from  tlie  gall-bladder.  The 
existence  of  the  stone,  and  the  adhesion 
of  the  gall-bladder  being  ascertained,  the 


opeiation  Avill  be  without  danger.'  He 
describes  the  mode  of  sounding  for  gall- 
stones, by  first  tapping  with  a  trocar, 
and  then  passing  a  long  flexible  probe 
through  the  canula,  which,  when  a  stone 
is  found,  serves  as  a  guide  to  a  bistoury. 
An  opening  is  made  of  sufficient  size  to 
admit  forceps  and  remove  stones.  In  one 
case  he  removed  in  this  way  a  stone  as 
large  as  a  pigeon's  egg  successfully  ;  and 
he  relates  other  cases  where  numerous 
stones  Avere  found  after  death  which 
might  have  been  safely  removed,  as 
adhesions  Avere  firm.  In  one  case,  after  a 
spontaneous  opening,  a  large  number  of 
stones  came  aAvay  during  2  months,  when 
the  fistulous  opening  Avas  enlarged  after 
sounding,  and  a  stone  successfully  re- 
moved. He  says,  also,  that  this  has  been 
done  by  other  surgeons  after  dilating 
the  opening  by  sponge  tents.  In  one 
case  a  stone,  3  inches  in  circumference 
and  4  inches  long,  Avas  broken  into  several 
pieces  by  the  forceps  before  extraction  ;  a 
2nd  stone  Avas  also  removed,  and  perfect 
recovery  folloAved. 

Godefroy  Mliller's  incision  of  a  biliary 
fistida,  and  extraction  of  a  gall-stone  after 
breaking  it  up,  might  have  been  com- 
pared Avith  a  combined  lithotomy  and 
lithotrity. 

In  the  chapter  on  Diagnosis,  at  page 
2G,  some  record  may  be  Ibund  of  cases 
Avhere  I  have  tapped  and  aspirated  hydatid 
cysts  of  the  liver,  and  a  few  remarks  iipou 
injection  of  iodine  and  drainage.  I  have 
never  tapped  the  gall-bladder  nor  removed 
a  gall-stone  myself;  but  I  once  assisted 
Mr.  Meredith  in  removing  3  gall-stones, 
Avhich  together  Aveighed  1  ounce  and  2G 
grains.  We  had  both  carefully  studied  the 
case  of  Sims's  patient.  She  Avas  45  years  of 
age.  Simsremovedfromherdistended  gall- 
bladder 24  ounces  of  fluid  and  GG  stones. 
He  then  cut  away  part  of  the  gall-bladder 
and  sewed  the  other  part  to  the  abdominal 
Avail,  thus  forming  a  biliary  fistula.  After 
death  on  the  iJth  day,  IG  more  stones  Avere 
found  in  the  gall-bladder.  In  the  same 
year  (187S)  Kocher,  of  Berne,  did  the 
first  successful  intentional  cholecystotomy, 
as  Bobbs's  operation  Avas  exploratory. 
Kocher's  patient  Avas  a  Avoman  30  years 
old.  The  gall-bladder  Avas  the  size  of  a 
man's  head,  and  contained  pus  and  32 
stones.  A  fistula  Avas  formed  in  this 
case.  As  a  result  of  experiments  on  dogs 
and  cats,  proving  that  the  gall-bladder  in 
these  animals  may  be  safely   extirpated, 


LIVER   AM)   GALL-BLADDER 


203 


Langenbucli,  in  1SS2,  not  only  removed  2 
gall-stones  from  the  thickened  and  dis- 
tended gsll-bladder,  but  he  tied  the  cystic 
duct  with  silk  and  dissected  away  the 
gall-bladder.  His  patient,  a  man  43  years 
old,  recovered.  Also  in  1882,  Wini- 
warter cured  a  man,  34  years  old,  by 
establishing  a  communication  not  only 
from  the  dilated  bladder  through  the 
abdominal  Avail,  but  also  into  the  trans- 
verse colon.  Several  other  cases — some 
of  them  very  imperfectly  recorded — may 
be  referred  to  in  an  able  paper  by  Musser 
and  Keen  in  the  '  American  Journal  of 
the  Medical  Sciences,'  of  October,  1884. 
These  Aviiters  justly  give  Thudichum  the 
credit  of  being  the  first  to  propose  the 
operation  of  cholecystotomy  in  his  paper 
on  gall-stones  in  the  '  British  Medical 
Journal '  in  1859 ;  but  they  claim  for 
Bobbs  and  Sims  the  merit  of  having  been 
the  first  to  carry  the  proposal  into  prac- 
tice. What  remains  for  us  is  to  perfect 
the  different  steps  of  the  operation.  In 
Mr.  Meredith's  case,  after  exposing  the 
distended  gall-bladder,  he  emptied  it  by  a 
fine  trocar,  drew  the  walls  carefully  for- 
ward, opened  the  cystlike  cavity,  and  ex- 
tracted a  gall-stone  by  forceps.  It  w^as 
j^roposed  to  stitch  the  opening  to  that  in 
the  abdominal  wall ;  but  there  would 
have  been  so  much  ti'action  that  it  was 
thought  safer  to  close  the  opening  in  the 
gall-bladder  by  stttures  and  return  it.  We 
thought  of  tying  up  the  opening  by  a 
circular  loop  of  silk,  like  a  purse ;  but 
found  it  difficult  to  accomplish. 

After  death  it  was  found  that  the  gall- 
bladder contained  about  half  a  pint  of 
bile,  the  cystic  and  common  ducts  were 
quite  free,  and  there  was  bile  in  the  duo- 
denum. The  opening  in  the  coats  of  the 
gall-bladder  was  so  well  closed  tliat  there 
was  no  escape  when  the  cavity  was  fully 
distended  by  injecting  water,  and  yet  some 
bile  was  found  in  the  peritoneal  cavity. 
Whether  this  escaped  unnoticed  during 
the  operation,  or  oozed  out  during  the 
short  time  immediately  afterwards,  before 
union  was  completed,  must  remain  in 
doubt.  The  coats  Avere  so  thin,  that 
inversion  and  stitching  of  the  serous  coat 
only,  as  suggested  before  operation,  was 


found  to  be  very  difficult  or  impossible. 
In  any  future  case,  the  question  whether  a 
biliary  fistula  should  be  formed,  or  the 
opening  in  the  gall-bladder  be  closed  by 
sutures,  or  the  gall-bladder  cut  away  after 
tying  the  cystic  duct,  must  be  determined 
by  the  peculiarities  of  the  case ;  and  the 
possibility  of  establishing  a  fistulous  com- 
munication between  the  gall-bhidder  and 
the  intestine,  after  Winiwarter,  supported 
as  it  is  by  the  more  recent  experiments  on 
dogs  by  Dr.  Gaston,  of  Atlanta,  Georgia 
— described  in  the  '  British  Medical 
Journal,'  February  14,  1885 — may  also 
be  borne  in  mind.  What  we  need  is  fur- 
ther experience  and  accurate  records  of 
all  cases.  The  reports  of  some  of  the 
more  recent  operations  are  so  incomplete 
that  they  are  qtiite  destitute  of  any  scien- 
tific or  practical  value. 

CnOLECTSTECTOilT 

or  excision  of  the  gall-bladder,  has  been 
successfully  performed  by  Langenbuch,  in 
a  case  where  a  thickened  and  adherent 
gall-bladder,  containing  many  gall-stones, 
was  first  emptied  by  a  syringe.  The  liver 
was  raised,  the  stomach  and  small  intes- 
tines protected  by  sponges,  and  the  gall- 
bladder was  separated  from  the  liver  by  a 
few  strokes  of  a  scalpel.  The  cystic  duct 
was  tied  in  two  places  with  silk,  and  the 
duct  divided  between  the  ligatures.  Gross 
has  also  removed  the  gall-bladder ;  and 
Thiriar,  of  Brussels,  brought  a  2nd 
successful  case  of  removal  of  gall-stones 
and  extirpation  of  the  gall-bladder  before 
the  Belgian  Eoyal  Academy  of  Medicine 
in  February  1885.  The  patient  was  25 
years  of  age,  in  the  4th  month  of  preg- 
nancy. The  report  of  the  full  discussion 
on  these  cases  has  not  yet  reached  me,  but 
we  have  already  sufficient  proof  that  this 
operation  ought  to  be  done  rather  than 
cholecystotomy  when  the  gall-bladder  is 
hypertrophied,  or  otherwise  diseased. 
Indeed,  it  appears  not  very  improbable 
that  cholecystectomy  may  prove  to  be 
better  practice  than  either  the  formation 
of  a  biliary  fistula  or  suture  of  the  open- 
ing in  the  coats  of  the  gall-bladder  after 
cystotomy. 


204 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


CHAPTER  VI 

MESEXTERIC,    OMENTAL  AND   PANCREATIC  CYST^ -UNDESCENDED 

TESTICLE 

MESENTERIC   CYSTS 


My  last  work  on  ovarian  and  uterine 
tumours  was  published  in  May  1882. 
Up  to  tliat  date  I  had  not  met  with  a  case 
of  a  mesenteric  cyst  nor  with  a  large 
mesenteric  tumour.  But  within  a  month 
I  had  opened  and  drained  a  large 
mesenteric  cyst,  and  had  removed  a  large 
solid  mesenteric  tumour.  Since  that  time 
I  have  not  seen  another. 

The  cyst  was  in  a  lady,  G3  years  of 
age,  a  patient  of  Dr.  Duke,  of  St.  Leonards. 
The  daughter,  then  33  years  old,  told  me 
that  her  mother's  illness  was  one  of  the 
recollections  of  her  early  childhood,  and 
that  the  tumour  began  as  a  small  lump  on 
the  right  side  of  the  abdomen  and  gradually 
increased.  She  had  been  under  medical 
care  for  many  years,  and  saw  me  in  1871 
and  1872,  when,  as  there  were  no  urgent 
symptoms,  I  advised  her  to  wait.  She 
went  on  for  more  than  10  years  without 
much  increase  in  size,  but  latterly  there 
had  been  a  rather  rapid  increase,  and 
her  life  had  become  that  of  an  invalid. 
Dr.  Sedgwick  afterwards  told  me  that, 
about  the  year  1858,  he  had  suspected 
mesenteric  disease,  that  Baker  Brown  had 
treated  her  for  uterine  disease,  and  Dr. 
West  for  movable  kidney.  I  operated  at 
St.  Leonards,  June  11,  1882,  assisted 
by  Dr.  Duke,  Mr.  Ticehurst  administering 
methylene.  Alter  a  little  peritoneal  fluid 
had  escaped,  I  tapped  and  emptied  a  very 
thin  cyst,  which  contained  about  6  pints 
of  reddish- brown  turbid  fluid,  quite  free 
from  odour,  with  l)roken-down  blood  clot 
and  a  good  deal  of  cholesterine.  On  ex- 
amining the  interior  of  this  cyst  when 
emptied,  I  found  that  it  had  formed  near 
the  root  and  between  the  two  layers  of  the 
mesentery,  extending  toward  the  ca;cum 
and  behind  the  ascending  colon,  its  lower 
end  being  so  spread  over  the  tipper  part 
of  the  pelvis  that  I  could  not  make  out 
clearly  either  uterus  or  ovaries.  The 
liver  and  spleen  were  both  somewhat  en- 
larged. Alter  considering  the  question  of 
drainage,  we  decided  against  it,  and  were 
content  with  carefully  sponging  out  the 
interior  of  the  cyst  ;ind  closing  the  wound. 


The  patient  went  on  remarkably  well  at 
first.  Dr.  Duke  wrote  to  me  on  the  19th 
that  he  had  removed  the  stitches  and  the 
wound  was  healed,  that  the  temperature 
had  never  exceeded  100°  nor  her  pulse 
90.  But  soon  afterwards  she  became 
jaundiced,  and,  without  there  being  any 
signs  of  the  reformation  of  fluid,  got  gra- 
dually weaker  and  died  on  July  13.  No 
post-mortem  examination  having  been 
made,  I  regret  that  I  cannot  give  a  more 
complete  account  of  this  unusual  case. 

A  mesenteric  cyst  was  removed  in  the 
Beaujon  Hospital,  Paris,  by  M.  Tillaux, 
from  a  man  31  years  of  age.  It  was  about 
the  size  of  the  head  of  a  foetus.  It  was  a 
cyst  containing  caseous  matter  springing 
from  the  mesentery  by  a  pedicle.  This 
was  tied  with  catgut,  the  abdomen  closed, 
and  jjerfect  recovery  ensued. — '  Lancet,' 
August  18  SO. 

Again,  in  the  '  British  Medical  Journal' 
for  January  1883,  Dr.  C.  H.  Carter  gives 
an  account  of  a  case  Avith  all  the  indica- 
tions of  a  unilocular  ovarian  cyst.  During 
the  operation  it  was  found  that  there  were 
no  pelvic  attachments.  The  cyst  rose 
from  the  left  lumbar  region,  surrounded 
by  coils  of  adhering  intestine.  It  could 
not  be  removed,  and  treatment  by  drainage 
Avas  adopted.  The  Avoman  died  on  the 
6th  day,  of  septiccemia.  There  Avas  a 
broad  attachment  to  the  side  of  the  spine 
and  the  left  lumbar  region,  closely  packed 
in  among  the  adhering  bowels.  On  the 
left  side  of  the  cyst  the  peritoneal  coat 
had  been  stripped  ofl"  by  an  extravasation 
of  blood  from  a  large  opened  vein. 

OMENTAL    CYSTS 

An  interesting  case  of  cyst  of  the 
great  omentum,  by  j\Ir.  Doran,  may  be 
found  in  the  23rd  volume  of  the  Obstetrical 
Transactions.  Mr.  Thornton  published 
in  the  '  British  INIedical  Journal,'  in  1882, 
an  account  of  a  case  of  mesenteric  tumour 
for  which  he  operated  in  1877,  adding 
notes  in  the  same  paper  of  two  cases 
Avhere,  in  the  course  of  ovariotomy,   he 


MESENTERIC,   OMENTAL,   AND   PANCREATIC   CYSTS 


205 


removed  cysts  from  tlie  omentum.  One 
was  as  large  as  a  cocoa-nut,  with  a  thick, 
fleshy  wail,  attached  to  the  omentum  by  a 
thick  vascular  pedicle,  and  was  high  up  in 
the  abdomen  under  the  right  border  of  the 
liver.  The  other  was  a  very  small  multi- 
locular  cystic  tumour,  in  a  case  of  ruptured 
papillomatous  cysts  of  both  ovaries.  Tliis 
tumour  was  attached  by  a  small  pedicle 
to  the  lower  border  of  the  omentum  and 
probably  had  its  origin  in  cell  infection. 
The  tumour  removed  in  1877  was  a  large 
thin  cyst  connected  with  the  mesentery  of 
a  portion  of  small  intestine  by  a  broad 
vascular  pedicle.  The  left  ovary  and 
tube,  being  adherent  to  a  fringe  of  solid 
growth  along  the  lower  border  of  the 
mesenteric  cyst, were  removed  with  it.  The 
solid  parts  weighed  G  pounds  4  ounces, 
and  there  were  19  pints  of  fluid  in  the  cyst. 
The  patient  was  in  good  health  5  years 
afterwards. 

Mr.  Thornton  alludes  to  other  cases 
which  might  have  been  mistaken  for 
omental  tumours,  but  which  resembled 
several  cases  that  I  have  recorded,  where, 
after  twisting  of  the  pedicle,  ovarian 
tumours  were  completely  detached  from 
the  uterus,  and  had  derived  their  prin- 
cipal blood-supply  from  adhering  omen- 
tum. 

SOLID    TUMOUR    OF    MESENTERY 

Assisted  by  Mr.  Jackson,  Mr.  Favell, 
and  Dr.  Redpath,  Mr.  Shaw  administer- 
ing methylene,  I  removed  at  Sheffield,  on 
June  20,  1S82,  a  solid  tumour  from  a 
married  lady,  40  years  of  age,  a  patient 
of  Mr.  Arthur  Jackson.  She  had  been 
married  18  years,  but  had  no  children, 
though  she  had  a  premature  labour  some 
months  after  marriage.  Two  or  three  early 
abortions  followed,  and  no  further  preg- 
nancy. She  was  in  good  health  until 
about  4  years  before,  when  pain  in  the 
iliac  regions  and  slight  abdominal  enlarge- 
ment were  noticed ;  but  no  tumour  was 
discovered  until  early  in  1881.  After 
that,  increase  was  very  manifest,  with 
some  apparent  diminution  after  each 
menstrual  period.  Various  opinions  were 
given  as  to  the  nature  of  the  tumour — 
some  believing  it  to  be  ovarian,  others 
uterine.  I  frankly  confessed  my  own 
inability  to  give  a  positive  opinion  as 
to  its  nature  or  connections ;  but  ex- 
pressed a  ■  confident  belief  that  I  could 
remove  it  without  any  unusual  difficulty 


or  danger.  It  was  ([uite  solid,  central  in 
the  abdomen,  freely  movable,  about  the 
size  of  an  adult  head,  and  imparting 
transmitted  rather  than  associated  move- 
ments to  a  uterus  somewhat  enlarged. 
Phenolised  spray  and  all  the  usual  anti- 
septic precautions  and  dressings  were 
carefully  employed.  The  tumour  was 
solid,  and  its  origin  was  clearly  in  the 
cellular  tissue,  at  the  root  of  the  mesentery 
proper,  near  the  lumbar  vertebra}.  The 
ascending  colon  was  closely  connected 
with  the  tumour  in  front,  and  to  the 
right.  All  its  blood-supply  was  derived 
from  the  mesenteric  vessels.  Those  which 
were  divided  were  secured  with  carbolised 
silk,  the  ends  of  all  the  ligatures  cut  off 
short,  and  returned.  The  uterus  and 
both  ovaries  were  healthy.  No  drainage 
was  employed,  and  the  wound  was  closed 
exactly  as  after  ovariotomy.  There  Avas 
some  sickness  during  the  first  3  days ;  but 
recovery  may  be  said  to  have  followed 
without  fever.  The  highest  temperature 
was  on  the  3rd  day,  but  was  only  100°. 
The  patient  left  her  bed  on  July  12,  and 
I  saw  her  in  London  in  the  summer  of 
1884  in  excellent  health. 

The  tumoiir  was  sent  to  the  Sheffield 
Pathological  Society  for  examination  and 
report.  I  have  not  yet  received  the 
report,  which  I  much  regret,  as  the  re- 
moval of  a  solid  mesenteric  tumour  may 
still  be  regarded  as  a  surgical  curiosity. 

In  the  chapter  on  Diagnosis,  several 
cases  of  abdominal  tumours,  both  cystic 
and  solid,  which  had  been  mistaken  for 
ovarian  cysts,  have  been  recorded,  such 
as  distended  bladder,  faecal  accumulations, 
pelvic  cellulitis  and  abscess,  hajmatocele, 
hydatids,  enchondroma  or  osseous  tu- 
mours, curvature  of  the  lumbar  vertebra?, 
diseased  lumbar  glands,  aneurism  o£  the 
aorta  and  extra-uterine  foitation.  Some 
of  these  were  surgical  curiosities,  and 
illustrated  the  difficulties  of  diagnosis ;  in 
others  the  surgical  treatment  is  related  in 
connection  with  the  history  of  the  case,  and 
will  be  found  on  referring  to  the  chapter. 

PANCREATIC    CYSTS 

Cases  of  hydatid  cysts  of  the  pancreas 
are  on  record ;  but  the  more  frequent 
cause  is  obstruction  of  the  duct  by  cal- 
culous concretion,  or  cancer — leading  to 
cystic  dilatation  behind — compared  by  Vir- 
chiJw  to  salivary  cysts,  and  named  by  him 
'  Ranula  pancreatica.'     These  cysts  may 


206 


UTERINE   AND   OTHER   ABDOMINAL   TUMOURS 


^ 


contain  only  a  few  ounces,  but  Bozeman 
has  narrated  a  case  where  about  20  pints 
of  fluid  were  drawn  off,  and  the  tumour, 
inchiding  the  fluid,  weighed  20i  pounds. 
He  operated,  believing  the  cyst  to  be 
ovarian;  but  found  that  it  was  pan- 
creatic, with  a  pedicle  nearly  an  inch 
long.  The  pedicle  was  tied,  the  cyst  cut 
away,  and  the  patient  recovered.  Eoki- 
tansky  also  operated  in  a  case  which  he 
thought  to  be  ovarian.  He  was  prevented 
by  adhesions  from  completing  the  opera- 
tion, and  the  patient  died  on  the  10th 
day.  Other  cases  are  on  record  where 
pancreatic  cysts  have  been  simply  tapped, 
or  tapped  and  drained,  or  opened  after 
stitching  the  cyst  to  the  abdominal  wall. 
But  pancreatic  cysts  must  be  very  rare, 
as  I  have  never  seen  one. 

A  case  is  related  by  Gussenbauer,  in 
the  'Archiv.  fiir  Klin.  Chir.'  1,  xxiv. 
p.  355,  1884,  of  a  man  who,  with  pain, 
sickness,  and  emaciation,  had  a  tumour  in 
the  epigastric  region,  extending  over  a 
space  of  22  centimetres,  and  passing  down 
as  low  as  the  umbilicus.  An  incision  was 
made,  and  the  wall  of  the  cyst  fixed  in 
the  wound,  peritoneum  to  peritoneum.  A 
portion  of  the  fluid  contents  was  taken 
away  by  trocar  ;  then  the  opening  in  the 
cyst  was  enlarged,  and  a  quantity  of  dark- 
coloured  matter  removed  from  the  cyst 
wall,  which  was  thin  and  smooth,  and, 
when  pressed  back,  allowed  the  finger  to 
feel  the  pancreiis  and  aorta.  The  man 
recovered,  the  cyst  contracted,  and  only  a 
thin  colourless  liquid  was  secreted,  which 
had  all  the  characters  of  the  pancreatic 
juice.  In  about  3  months'  time,  only  a 
small  fistula,  not  more  than  3  centimetres 
deep,  remained. 


UNDESCENDED    TESTICLE 


The  only  case  which  I  have  now  to 
add  is  almost  unique;  a  large  abdominal 
tumour  having  been  formed  by  the  en- 
largement and  degenerative  changes  of  an 
undescended  testicle.  The  patient  was  a 
middle-aged  German  gentleman,  father  of 
children,  whom  I  saw  early  in  1878,  in 
consultation  with  Sir  James  Paget.  All 
the  lower  part  of  the  abdomen  was 
occupied  by  a  solid  tumour.  The  left 
testicle  Avas  normal,  the  right  had  never 
descended,  but  had  not  begun  to  enlarge, 
or  at  least  to  attract  notice,  until  about  a 
year  before  I  saw  him.  As  he  was  in 
fairly  good  health,  and  not  suffering  much 


pain,  at  Sir  James  Paget's  suggestion  he 
Avas  put  iipon  liquor  potassa^  in  large 
doses,  and  went  to  the  .seaside.  He 
returned  after  a  few  weeks  with  the 
tumour  both  larger  and  softer,  suffering 
more  pain,  and  the  general  health  mani- 
festly giving  away.  It  was  accordingly 
arranged  in  consultation  that  I  should 
remove  the  tumour,  and  I  accordingly 
did  so  on  April  16,  1878. 

Present :  Sir  J.  Paget,  Bart. ;  Dr. 
Oscar  Liebreich,  of  Berlin  ;  Dr.  Junker  ; 
Dr.  Woodliam  Webb ;  and  Mr.  Thornton. 
Dr.  Day  administered  chloromethyl.  Thy- 
mol spray  was  used,  and  all  the  instru- 
ments and  sponges  were  bathed  in  warm 
thymol  solution — 1-1000.  I  made  an 
incision  in  the  linea  alba  from  1  inch 
above  to  5  inches  below  the  umbilicus. 
On  dividing  the  peritoneum  a  free  tu- 
mour was  seen,  very  much  like  a  large 
uterus  covered  by  a  thin  membranous 
capsule,  in  which  large  veins  ramified. 
Passing  my  hand  backwards,  I  found  such 
close  attacliments  behind,  that  removal  of 
the  capsule  (tunica  vaginalis)  would  have 
been  impossible.  I  accordingly  divided 
the  capsule  in  front,  and  began  to  separate 
it  from  the  enlarged  testis.  In  doing 
this,  and  pressing  the  whole  tumour  for- 
Avard,  a  large  cyst  burst,  and  some  2  or  8 
pints  of  fluid  Avere  expelled  with  great 
force.  I  then  broke  away  all  the  loose 
portions  of  the  tumour,  and  separated  the 
deeper  part  from  the  capsule  by  tearing, 
and  an  occasional  touch  of  the  scissors. 
Several  blood-vessels  Avere  temporarily 
secured  by  torsion  forceps,  and  the  vessels 
afterwards  tied.  All  the  ligatures  Avere 
cut  short,  some  portions  of  the  capsule 
Avere  cut  oflf,  all  clot  sponged  from  the 
cavity,  and  the  Avound  in  the  abdominal 
wall  closed  Avith  sutures,  as  in  ovariotomy. 
Ver}'-  little  blood  was  lost.  The  operation 
lasted  three-quarters  of  an  hour.  The 
patient  soon  began  to  complain  of  pain,  and 
opiates  Avere  given  by  mouth  and  rectum. 
Nine  hours  after  operation,  about  a  pint  of 
urine  Avas  draAvn  ofl"  by  catheter.  At  night 
he  Avas  comfortable  ;  had  not  been  sick  ; 
pulse  100;  skin  moist;  temperature  nor- 
mal. After  this  lever  set  in,  and  rapidly 
increased.  He  died  on  the  ord  day 
Avitli  precisely  the  same  symptoms  of 
peritonitis  or  septicaemia  so  often  de- 
scribed as  septic  peritonitis,  and  the  most 
frequent  cause  of  death  after  the  removal 
of  abdominal  t^^mours  of  any  kind.  Esti- 
mating the  fluid  Avhich  escai^ed  at  _  or  0 


STOMACH  7VND   INTESTINES 


207 


pints,  the  ■whole  tumour  weighed  about  9 
pounds.  It  was  sent  to  the  College  o£ 
Surgeons.  No  doubt  was  entertained  as 
to  tlie  malignant  character  of  tlie  growth, 
but  there  was  no  evidence  of  disease 
liaving  extended  beyond  the  capsule.  If 
it  had   not  been  for  the  septica}mia  the 


patient  probably  would  have  recovered, 
and  there  would  not  have  been  greater 
fear  of  the  recurrence  of  the  disease  or  of 
its  appearance  in  any  other  part  of  the 
body  than  if  the  diseased  testicle  had 
been  removed  from  the  scrotum. 


CHAPTER  VII 
THE  STOMA  CII  AND  INTESTINES 

gastrostomy;  GASTROTOMY  ;  DILATATION  OF  CARDIAC  AND  PYLORIC  ORIFICES;  PYLO- 
RECTOJIY  ;  OBSTRUCTED  INTESTINE  ;  ENTEROTOMY  AND  COLOTOMY ;  ARTIFICIAL 
ANUS,    RESECTION    OF    INTESTINE  ;     OPERATIVE    TREATMENT    OF    PERITONITIS 


All  the  operations  incladed  in  the  head- 
ing of  this  chapter  have  received,  and  are 
now  receiving,  a  remarkable  impulse  from 
the  influence  which  the  revival  of  ovario- 
tomy has  had  upon  modern  surgery.  It 
is  ti'ue  that  intestinal  obstruction  has  been 
treated  by  colotomy,  in  one  or  other  loin, 
since  the  days  of  Littre  and  Pillore,  and 
of  Callisen  and  Amussat.  Dupuytren's 
treatment  of  artificial  anus  by  his  entero- 
tome  was  in  vogue  more  than  50  years  ago. 
Gastrostomy,  from  the  time  of  the  experi- 
ments on  Alexis  St.  Martin,  though  very 
rarely,  has  been  occasionally  practised  to 
prolong  life  in  cases  where  the  oesophagus 
has  been  closed  by  malignant  disease,  or 
by  the  pressure  of  a  tumour.  But  it  is 
only  by  the  experience  of  ovariotomists 
we  have  learned  that,  if  intestine  be 
accidentally  wounded,  and  the  wound 
be  carefully  and  completely  closed  by 
sutures  properly  applied,  the  recovery  of 
the  patient  is  not  hopeless ;  that  even 
some  portions  o£  intestine  may  be  removed 
and  the  patient  recover,  if  tlie  continuity 
of  the  canal  is  restored  by  suture.  Although 
in  one  case  where  I  did  this,  after  remov- 
ing 3  inchesof  intestine  during  ovariotomy, 
the  patient  died,  it  was  proved  that  union 
of  the  intestine  was  complete,  and  that 
the  death  was  not  due  to  this  complication. 
It  was  Koeberle's  extraordinary  case,  re- 
corded in  the  Memoirs  of  the  Socicte  de 
Chirurgie,  in  1881,  where  the  patient 
recovered  after  the  removal  of  more  than 
G  feet  of  small  intestine,  Avhich  first  effec- 
tually aroused  professional  attention  to  the 
possibility  of  excising  portions  of  intestine, 
and  either  restoring  the  continuity  of  the 
canal  immediately  by  suture,  or  secondarily, 


after  the  temporary  formation  of  an  arti- 
ficial anus. 


GASTROSTOMY 

I  need  not  say  more  now  of  this  operation 
than  I  said  in  an  address  delivered  at  Bir- 
mingham in  Nov.  1884,  that  'no  one  who 
has  watched  the  progress  of  these  opera- 
tions, has  considered  the  causes  of  death  in 
fatal  cases,  and  the  details  of  the  operative 
proceedings  in  successful  cases,  can  come 
to  any  other  conclusion  than  that  one 
important  element  in  the  attainment  of 
success  is  the  scrupulous  observance  of 
the  principles  laid  down  as  necessary  to 
success  in  ovariotomy^ — not  only  as  regards 
the  hygienic  precaiitions  never  omitted  in 
modern  surgery,  but  especially  as  to  the 
importance  of  a  very  accurate  and  exact 
union,  not  only  of  the  edges,  but  of  the 
surfaces  of  the  peritoneal  surface  of  the 
viscera  and  of  the  abdominal  wall.  In 
gastrostomy,  for  instance,  it  is  found  that 
when  the  stomach  is  attached  to  the  ab- 
dominal Avail  by  a  single  ring  of  sutures, 
the  weak  attachment  may  give  wa}-,  and 
risk  of  extravasation  into  the  peritoneal 
cavity  may  be  great.  But  Avlien,  after 
dividing  the  abdominal  wall,  the  parietal 
peritoneum  is  sewn  to  the  skin  all  round 
the  opening,  a  broad  surface  of  visceral 
and  parietal  peritoneum  may  afterwards 
be  maintained  in  contact  by  a  circle  of 
sutures,  forming  loops,  passed  through  the 
peritoneal  coat  of  the  protruding  portion 
of  stomach,  and  through  the  whole  thick- 
ness of  the  abdominal  wall,  about  half  an 
inch  from  the  edge  of  the  incision.  Smaller 
fine  sutures  beino:  inserted  between    the 


208 


L'TEPJXE   AND   OTHER   ABDO:\JIXAL   TUMOURS 


laro-er  ones,  a  very  close  and  secure 
attachment  of  the  stomach  to  the  peri- 
toneal lined  opening  in  the  abdominal 
wall,  and  complete  occlusion  of  the  peri- 
toneal cavity,  are  guaranteed.  This  done, 
we  have  an  example  of  the  carrying  out 
in  its  integrity  of  one  of  the  fundamental 
rules  of  practice  in  the  operation  of 
ovariotomy  as  regards  the  peritoneum — 
surface  to  surface,  not  edge  to  edge  merely 

and  it  is  a  fact  not  to  be  overlooked, 

that  in  gastrostomy  the  result  of  the 
operation  seems  to  depend  upon  it _;  the 
rule  being  that  the  cases  in  which  it  has 
been  neglected  fail,  while  those  in  which 
it  is  observed  end  satisfactorily.  Thus 
the  lessons  learnt  at  an  early  stage  of  our 
experience  in  one  operation  have  been 
the  means  of  leading  directly  to  the  suc- 
cessful performance  of  the  other.' 

In  reference  to  the  mode  of  operating, 
I  need  only  say  that  the  incision  should 
be  made  about  |  of  an  inch  below  the  free 
margin  of  the  cartilages  of  the  7th,  8th 
and  9th  ribs  on  the  left  side.  The  liver 
is  usually  seen  at  the  upper  end  of  the 
incision,  and  is  a  good  guide  to  the 
stomach,  which  is  immediately  beneath 
it.  The  centre  of  the  anterior  surface  of 
the  stomach  is  the  part  usually  opened, 
but  in  the  absence  of  some  very  immediate 
necessity  for  feeding  by  tlie  stomach,  it  is 
better  not  to  open  it  until  a  firm  union  of 
the  peritoneal  surfaces,  kept  together  by 
the  sutures,  has  been  obtained.  There 
can  then  be  no  fear  of  the  escape  of  any 
of  the  contents  of  the  stomach  into  the 
peritoneal  cavity.  When  the  opening  is 
made,  it  need  not  be  larger  than  is  required 
for  the  passage  of  the  teeding-tube. 

GASTROTOMY 

or  incision  of  the  stomach,  for  the 
removal  of  a  foreign  body,  has  l)een 
performed  successfully  by  SchiJnborn, 
and  by  iSIr.  Thornton,  in  order  to  ex- 
tract masses  of  hair.  In  Mr.  Thornton's 
case  the  mass  weighed  2  pounds.  It  was 
moulded  into  the  shape  of  the  stomach. 
The  incision  across  the  greater  curvature 
was  5  inches  long.  Fifteen  deep  sutures 
were  passed  through  peritoneum,  mus- 
cular coat,  and  edge  of  the  mucous  mem- 
brane. Fifteen  superficial  sutures  were 
passed  through  the  peritoneum  only,  and 
a  very  fine  continuous  suture  over  all 
united  the  opening  in  the  coats  of  the 
stomach.     The  abdomen  was  closed  as  in 


ovariotomy,  and  the  patient  perfectly  re- 
covered. 

Professor  Loreta,  of  Bologna,  has 
performed  gastrotomy  in  order  forcibly  to 
dilate  the  pyloric  orifice,  by  inserting  first 
one  index  finger,  then  the  other,  and  so 
effecting  foi'cible  dilatation,  just  as  is 
done  at  the  anus.  In  1883  he  published 
a  monograph  containing  two  successful 
cases.  The  opening  in  the  coats  of  the 
stomach  was  closed  by  silk  sutures,  not 
more  than  1  centimetre  apart,  including 
all  the  tissues  of  the  coats.  Using  a  long 
thread,  armed  at  each  end  with  a  needle, 
he  made  a  zigzag,  or  sort  of  glover's  suture, 
each  needle  crossing  alternately  from  left 
to  right.  The  operation  was  done  on  ac- 
count of  non-malignant  stricture.  Loreta 
has  since  dilated  the  cardiac  orilice  of  the 
stomach,  in  a  case  where  contraction 
follovved  the  destructive  action  of  a 
caustic  ;  and  oesophageal  bougies  or  tubes 
could  not  be  passed. 

EXCISION    OF    THE    PYLORUS 

A  clear  idea  may  be  formed  of  pylorec- 
tomy  by  a  glance  at  the  accompanying 
woodcut,  reduced  from  Wijlfler's  report 
of  one  of  Billroth's  cases.     It  shows  very 


clearly  how  the  opening  in  the  stomach, 
left  after  excision  of  the  diseased  part,  has 
to  be  diminished,  in  order  that  it*may 
correspond  with  the  smaller  opening  of  the 
intestine  after  the  pylorus  has  been  cut 
away.  I  have  only  twice  seen  a  case  where 
I  thought  this  operation  could  be  seriously 
advised.  One  patient  was  a  captain  of 
one  of  the  Cunard  steamers.  He  said  he 
would  submit  to  it  after  one  more  voyage 
to  New  York,  but  he  died  there  ;  and  I 
heard  afterwards  that  the  disease  was  so 
confined  to  the  pylorus  that  the  operation 
would   have  been  very  easy.     The  other 


ENTERECTOMY 


209 


patient  was  a  German  tailor,  who  after- 
wards died  in  the  Cancer  Hospital ;  when 
it  was  found  that  the  disease  of  the  pylorus 
had  just  begun  to  involve  the  liver.  Mr. 
Jennings  tried  to  prolong  life  by  injecting 
milk  into  a  vein  in  his  arm.  Never  having 
done  the  operation,  however,  I  think  it 
better  to  refer  anyone  proposing  to  do  it 
to  the  works  of  Wijlfler  aud  liydygier,  and 
to  Southam's  account  of  a  typical  pylorec- 
tomy  in  the  '  British  Medical  Journal'  of 
July  1882,  than  to  offer  any  description  of 
my,  own.  But  I  do  think  it  right  to  insist 
that,  belbre  any  siirgeon  attempts  to  excise 
the  pylorus,  or  any  portion  of  intestine  or 
the  uterus,  he  should  make  himself  fami- 
liar with  the  details  of  the  proceedings 
by  practice  on  the  dead  body.  At  post- 
mortem examinations,  whether  in  hospital 
or  private  practice,  or  in  our  workhouse 
infirmaries,  opportunities  may  be  obtained 
without  any  great  difficulty  for  the  practice 
of  such  operations.  And  I  think  it  quite 
inexcusable  for  anyone  who  has  neglected 
such  opportunities  to  undertake,  lor  the. 
first  time,  such  an  operation  iipon  any 
living  patient  before  he  has  had  some 
practice  on  the  dead  body. 

INTESTINAL    OBSTPaiCTION 

Operations  upon  the  intestines,  entero- 
tomy,  colotomy,  resection  of  intestine, 
scarcely  ever  become  subjects  for  con- 
sultation imtil  either  acute  or  chronic 
obstruction  of  intestine  has  produced 
symptoms  dangerous  to  life.  In  cases  of 
strangulated  hernia,  Avhere  a  portion  of 
intestine  has  become  gangrenous,  the 
removal  of  the  gangrenous  intestine, 
and  the  formation  of  an  artificial  anus, 
has  been  the  orthodox  practice  for 
genei'ations.  It  is  only  since  the  modern 
development  of  peritoneal  surgery  that 
abdominal  section  has  been  proposed  in 
cases  of  intussusception,  or  as  a  mode  of 
ascertaining  the  seat  of  obstruction  in 
cases  where  it  is  doubted  if  the  symptoms 
are  due  to  a  hernia-like  strangulation 
through  apertures,  or  by  bands,  or  by 
adhesion  of  coils  of  intestine  to  each 
other,  or  by  stricture,  by  compression  of 
the  intestine  by  tumours,  or  by  new 
growths  in  the  coats  of  intestines  them- 
selves, or  by  obstruction  of  the  canal  by 
gall-stones,  faecal  masses  or  concretions,  or 
by  a  paralytic  or  spasmodic  condition  of  the 
bowel.  The  conflict  between  the  surgery 
of  the  past  and  the  present  still  goes  on. 


"We  have  not  yet  sufficient  experience  to 
enable  us  to  lay  down  any  such  rules  as 
shall  prevent,  on  the  one  hand,  too  great 
haste  in  operating,  and  avoid,  oa  the 
other,  the  dangers  of  delay  too  long  con- 
tinned. 

I  said  in  the  address  at  Birmingham, 
from  which  I  have  already  quoted,  that 
in  Mr.  Treves's  Jacksonian  Prize  JCssay 
on  Intestinal  Obstruction,  puVjlished  last 
year,  'you  will  see  how  firmly  an 
operator  of  to-day  is  taking  his  stand 
on  the  true  principles  of  abdominal  sur- 
gery Avhich  we  have  watched  emerging 
from  their  obscurity.  lie  does  not  ignore 
the  teachings  from  experiments  upon 
animals.  He  supports  himself  by  the 
nine  successful  resections  of  lengths  of 
the  intestines  of  animals  made  by  Made- 
lung.  He  traces  the  failures  in  many 
operations  of  the  same  kind  on  the  hu- 
man subject  to  faults  in  the  details,  such 
as  want  of  perfect  adaptation  and  insuffi- 
ciency of  sutures.  And  he  lays  down  as 
rules  for  his  own  action  that  he  must 
separate  the  peritoneum  from  the  other 
tissues — introduce  abundance  of  sutures 
after  Lembert's  method — bringing  the 
two  serous  surfaces  together,  and  avoid- 
ing the  mucous  membrane  with  the 
needle.  A  recent  paper  by  Eeichel  in- 
forms us  that  already  121  cases  of  resec- 
tion of  intestine  have  been  collected,  the 
conclusion  being  that  the  two  ends  of  the 
bowel  should  not  be  united  at  the  time  of 
the  resection,  but  that  an  artificial  anus 
should  be  established.  This  can  be 
closed  by  a  subsequent  operation.'  Mr. 
Makins  has  had  a  successful  case  of 
artificial  anus  treated  in  St.  Thomas's 
Hospital  in  1884  by  resection  of  more 
than  3  inches  of  small  intestine,  and 
suture  of  the  upper  and  lower  ends. 
His  paper  in  the  loth  volume  of  St. 
Thomas's  Hospital  Eeports  is  a  valuable 
contribution  to  modern  surgery. 

Mr.  Jessop,  of  Leeds,  has  also  cured  a 
foBcal  fistula  by  separating  the  injured  in- 
testine from  the  abdominal  wall,  and 
uniting  the  upper  and  lower  parts  of  the 
gut  by  suture.  What  I  said  with  regard 
to  practice  on  the  dead  body  before  oper- 
ating on  living  women  is  equally  applic- 
able to  the  resection  of  intestine.  But 
here  practice  on  the  dead  is  not  sufficient, 
and  if  we  are  not  allowed  to  experiment 
on  living  animals  in  this  country,  we 
must  either  go  abroad  or  practise  on  men 
and   women.     By   my   advice   a   young 

p 


210 


UTERINE   AND   OTIIEE   ABDOMINAL   TUMOURS 


surgeon,  Mr.  Jennings,  from  whom  1  hope 
and  expect  great  things  in  the  future, 
and  who  is  jilready  one  of  the  junior 
surgeons  of  the  Cancer  Hospital,  has  re- 
cently cut  away  portions  of  the  intestines 
of  dogs,  uniting  the  upper  and  lower 
parts  so  as  to  maintain  the  continiiity  of 
the  canal.  Some  of  the  preparations  may 
be  seen  in  our  College  Museum,  and  they 
strongly  confirm  the  conclusion  that  suc- 
cess depends  upon  complete  union  of  the 
apposed  serous  surfaces.  In  order  to 
prevent  any  blood  or  faecal  matter  es- 
caping from  the  divided  intestine  into  the 
peritoneal  cavity,  clamps  have  been  de- 
vised by  Mr.  Treves  and  Mr.  Bishop  to 
compress  the  upper  and  lower  openings ; 
and  cylindrical  plugs  of  dough  or  decalci- 
fied bone  have  been  introduced  to  facili- 
tate the  introduction  of  the  sutures.  At 
my  suggestion,  Mr.  Jennings,  instead  of 
solid  plugs,  used  hollow  cylinders  of 
cocoanut  butter  and  of  gelatine.  He  had 
them  cast  in  eight  sizes,  conical  at  the 
extremities. 

Such  cylinders  afford  a  firm  basis  and 
support  for  the  intestine  during  the  opera- 
tion, and  will  not  collapse  (like  an  india- 
rubber  bag)  if  accidentally  wounded  by 
the  point  of  the  needle.  The  cylinders 
slowly  melt  during  the  first  few  hours 
after  these  operations,  thus  allowing  time 
for  adhesion  of  the  peritoneal  surfaces  at 
the  line  of  union,  but  not  too  slowly  to 
form  an  obstacle  to  the  passage  of  the 
faeces.  The  gelatine  have  the  advantage 
of  flexibility  over  the  cocoa-butter  cy- 
linders. 

So  far  as  can  be  gathered  from  three 
experiments  upon  dogs,  it  appears  : 

1.  That,  whenever  possible,  the  por- 
tion of  intestine  to  be  removed  should  be 
isolated  from  the  general  peritoneal  cavity 
])y  passing  it  through  a  small  aperture  in 
a  sheet  of  transparent  gutta-percha  tissue. 

2.  That  the  section  of  the  intestine 
should  be  slightly  oblique  to  lessen  the 
tension  on  the  line  of  suture,  and  to  pre- 
vent the  great  diminution  of  the  calibre 
of  the  intestine  at  the  seat  of  resection, 
which  obtains  when  the  division  is  trans- 
verse. 

3.  That  a  triangular  portion  of  the 
mesentery  should  be  excised,  the  base 
corresponding  to  the  part  of  the  intestine 
which  is  removed. 

4.  That  after  the  piece  of  intestine 
has  been  removed,  a  cylinder  slightly 
larger  than   the  calibre  of  the  intestine 


should  be  selected,  in  order  to  distend 
the  portions  to  be  united. 

5.  That  the  gap  in  the  mesentery 
should  be  closed  by  a  continuous  suture ; 
and  that  a  double  row  of  intestinal  sutures 
(each  commencing  where  the  mesentery 
joins  the  intestine)  should  be  employed 
to  maintain  the  peritoneal  surfaces  be- 
tween the  two  rows  in  contact.  The 
inner  row  should  unite  the  edges  of  the 
pieces  of  the  intestine :  the  outer  row 
should  include  only  peritoneum  or  peri- 
toneum and  muscularis.  By  this  means 
sufficient  peritoneal  surfaces  Avill  be 
maintained  in  contact :  but  if  only  one 
row  of  sutures  be  employed,  the  edges  of 
the  intestine  Avill  curl  away  from  each 
other,  internal  to  that  single  line  of 
sutures. 

6.  Fewer  sutures  should  be  employed 
for  the  inner  than  for  the  outer  row,  and 
the  stitches  in  the  latter  should  not  be 
more  than  one-tenth  of  an  inch  apart. 

7.  A  single  continuous  suture  (for 
each  row)  should  not  be  used ;  for  if  it 
be,  when  the  intestine  contracts  after  the 
operation,  the  ring  of  suture  will  not 
adapt  itself  to  the  lessened  calibre  of  the 
intestine,  and  fteces  will  escape  there- 
from ;  whereas,  if  interrupted  sutures  be 
employed,  when  the  intestine  contracts, 
the  points  of  suture  will  fall  still  closer 
together. 

8.  That  Ilageborn's  flat  needles  are 
to  be  preferred,  since  they  do  not  lacerate 
the  peritoneum  so  much  as  the  ordinary 
needles. 

9.  That  silk,  rendered  antiseptic, 
should  be  used  for  the  intestinal  sutures  : 
the  braided,  which  will  not  kink,  being 
better  than  the  ordinary  twist. 

OPERATIVE    TREATMENT    OF    PERITONITIS 

At  pages  331-33  of  my  work  on  Dis- 
eases of  the  Ovaries,  which  appeared  in 
18G5, 1  have  recorded  a  case  of  tubercular 
peritonitis,  where  recovery  followed  an 
exploi-atory  incision  and  removal  of  peri- 
toneal fluid.  That  patient  is  still  quite 
well,  23  years  after  the  operation,  al- 
though '  the  whole  of  the  peritoneum  was 
seen  to  be  studded  with  myriads  of 
tubercles,'  and  the  colon  and  omentum 
with  coils  of  small  intestine  were  bound 
down,  and  all  '  nodulated  by  tubercle.' 
I  concluded  by  saying,  '  The  case  would 
.serve  as  a  striking  appendix  to  Marten's 
curious  paper  on  the  operative  treatment 


OPERATIVE   TREATMENT   OF   PERITOMTIS 


211 


of  peritonitis.'  This  paper  may  be  found 
in  the  20tli  volume  of  Vircliow's  '  Archir.' 
published  in  18G].  Dr.  Marten,  of 
Iliirde,  there  narrates  two  cases  of  Avhat 
he  calls  '  empyema  abdominis  '  treated  by 
abdominal  section.  And  he  argues  that 
cases  described  as  chronic  peritonitis  with 
exudation,  or  Kup2:)urative  peritonitis,  or 
of  hajmorrhage  into  the  peritoneal  cavity, 
of  effusion  in  puerperal  peritonitis,  of 
perforation  of  intestine,  would  be  all 
better  treated  by  abdominal  section  along 
the  linea  alba  (he  uses  the  word  'lapa- 
rotomy') than  by  opium  euthanasia. 
Cases  may  be  found  at  long  intervals  in 
the  medical  journals  bearing  on  these 
questions;  but  the  first  really  important 
contribution  is  a  paper  by  Marion  Sims, 
in  the  '  British  MedicalJournal,'  1881-2, 
on  '  The  Treatment  of  Gunshot  Wounds  of 
the  Abdomen,  in  Relation  to  modern  Peri- 
toneal Surgery.'  In  his  usual  strikingly 
interesting  manner,  Sims  argues  that 
'  ovariotomy  is  the  parent  of  peritoneal 
surgery,'  that  '  other  wounds  of  the  peri- 
toneum follow  the  same  course  as  those 
made  by  the  surgeon's  knife  in  ovario- 
tomy,' and  that  in  all  septicaemia  is  the 
chief  danger.  The  time  will  come,  he 
says,  when  '  gunshot  and  other  wounds  of 
the  abdomen,  and  perforations  of  the  in- 
testine, will  be  treated  by  opening  the 
peritoneal  cavity,  and  washing  out,  or 
draining  off,  the  septic  fluids  that  would 
otherwise  poison  the  blood.'  In  all  cases 
of  wounds  of  stomach,  intestines,  or  blad- 
der— in  all  cases  of  haemorrhage  into  the 
peritoneal  cavity,  or  of  foreign  bodies 
there,  abdominal  section  should  be  the 
rule  of  treatment,  followed  by  any  sutures 
or  ligatures  that  may  be  required,  with 
such  -washing  and  drainage  as  the  nature 
of  the  injury  demands.  In  uniting  wounds 
of  the  intestines  Sims  refers  to  the  expe- 
riments of  Gross,  published  in  1843,  in 
favour  of  the  continued  suture  of  fine 
silk,  and  to  his  conclusion  in  1872,  that 
in  all  cases  of  wounded  intestine,  where 
there  is  no  protrusion,  the  surgeon  should 
'  enlarge  the  abdominal  orifice,  seek  for 
the  wounded  tube,  and  sew  up  the  cut,'  and 
thoroughly  cleanse  the  peritoneal  cavity. 


The  next  important  paper  on  this  sub- 
ject is  that  of  Mr.  Treves,  read  at  the 
Medical  and  Chirurgical  Society  in  March 
1855,  '  On  the  Treatment  of  Acute  Peri- 
tonitis by  Abdominal  Section.'  Free  in- 
cision and  drainage,  argued  Mr.  Treves, 
'has  been  already  ajjplied  for  the  relief  of 
inflammations  of  certain  of  the  serous 
membranes.  It  was  at  first  adopted  in 
connection  with  the  smaller  serous  cavi- 
ties, as  those  of  the  joints.  It  has  been 
gradually  and  with  increasing  freedom 
applied  in  the  treatment  of  inflammatory 
conditions  involving  the  pleura.  It  has 
finally  become  a  recognised  means  of 
treatment  in  certain  forms  of  localised 
and  chronic  peritonitis,  especially  when 
purulent  collections  have  formed.  The 
author  would  urge  the  adoption  of  this 
principle  in  treatment  in  connection  with 
acute  and  diffused  forms  of  peritonitis.' 

After  relating  a  very  successful  case 
where  acute  diffused  peritonitis  was 
treated  by  incision,  washing,  and  drainage, 
Mr.  Treves  advocates  '  abdominal  section 
in  the  treatment  of  certain  cases  of  a,cute 
general  peritonitis,  such  as  that  following 
injury,  gunshot  wound,  the  bursting  of 
an  abscess,  and  specified  forms  of  per- 
foration.' 

All  I  need  add  to  this  is  a  caution 
against  putting  off  the  operation  until  too 
late — until  the  patient  is  dying  of  sep- 
ticaemia. 


CONCLUSION 

It  appearing  that  in  a  work  on  Abdo- 
minal Tumours  it  would  be  rather  out  of 
place  to  enter  more  fully  upon  the  tempt- 
ing theme  of  the  operative  treatment  of 
obstructed  intestine,  or  to  do  luore  than 
allude  to  the  important  subject  of  excision 
of  the  rectum,  as  this  may  be  more  or  less 
an  extra-peritoneal  operation — a  consider- 
ation which  has  also  excluded  an  account 
of  the  operation  of  shortening  the  round 
ligaments  in  obstinate  cases  of  uterine 
prolapse  and  flexions — I  can.  only  com- 
mend the  careful  study  of  Peritoneal 
Surgery  to  the  Modern  Student. 


INDEX 


Abdomex,  structure  uf  Av;ills  of,  <S1 

Aljscess,  pelvic,  33 

Absence  of  ovaries,  1 

Accidents  during  ovariotomy,  97 

Acupressm-e,  9i 

Adhesions,  diagnosis  of,  5 ;  effect  of  on  ovario- 
tomy, 69 

Adhesive  straps,  nse  of  to  support  abdomen  after 
operation,  96 

Age,  average,  of  ovariotomy  patients,  71 ;  mor- 
tality at  different  ages,  71 

America,  ovariotomy  in,  67 

Amputation  of  uterus,  152 

Antiseptics,  .39 

Aorta,  compression  of,  177 

Arteries,  spermatic,  tying,  129,  172 

Ascites,  diagnosis  between  ovarian  dropsy  and, 
12 

Assistants,  position  of  in  ovariotomy,  80 

Atlee,  brings  forward  the  case  of  Houston,  48  : 
his  book  published  in  1872,  67 

Auscultation  in  diagnosis  of  ovarian  tumours, 
14  ;  of  uterine  tumours,  139 

Bandage  and  dressing,  96 

Battey,  his  operation,  12.5;  his  opinions,  128 

Belgium,  ovariotomy  in,  6-1 

J'ell,  John,  influence  of  his  lectures,  47 

Billroth,  results  of  his  ovariotomj',  remarks  by, 

66 
Bluudell  on  extirpation  of  ovaries,  12.5;  excision 

of  uterus,  177 
Boddaert,  operations  by,  64 
Boiaet,  on   contents   of  cysts,    "> ;    inj  action   of 

iodine,  45 

Canceb  of  peritoneum,  21 

Carbolic  acid,  my  early  use  of,  -57  ;  in  spray,  60  ; 

my  experience  of,  63 
Castration  of  women,  Fehling  on,  129 
Cautery  clamp,  78 
Cells  in  ovarian  fluids,  19 
Cellulitis,  pelvic,  33 


Chemical  examination  of  fluids  in  diagnosis,  1-5 

Children  born  after  ovariotomy,  131 

Cliloroform,  objections  to,  76 

Cholecystectomy,  203 

Cholecystotomy,  202 

Chronic  inflammation  of  peritoneum,  19,  211 

Clamp,  introduction  of,  .54;  modifications  of,  .55; 

use  of,  88 
Classification  of  ovarian  tumours,  1  ;  of  uterine 

tumours,  144 
Clay's  cautery  clamp,  94 
Colonies,  ovariotomy  in,  67 
Complication  of  ovarian  cysts  with  jJregnanc}', 

115  ;  of  uterine  tumours  with  pregnancy,  164 
Conditions  affecting  the  operation  of  ovariotom}-, 

67 
Conjugal  condition  as  affecting  ovariotomy,  71 
Contra-indications,  ovariotomy,  72 
Cysts,   ovarian,  classification    of,    1  ;    diagnosis 

of,  3  ;  renal,  diagnosis  of,  SO 


Diagnosis  of  different  kinds  of  ovarian  tumours, 

3  ;  of  adhesions,  5  ;  of  uterine  tumours,  137 
Differential  diagnosis  of  ovarian  tumours,  10 
Distended  bladder,  diagnosis,  32 
Doran  on  the  ligatures  of  stumps,  93 
Douglas's  pouch,  puncture  of  and  drainage,  110 
Dressing  and  bandage,  96 
Dry  dressing,  60 


Eaelt  history  of  ovariotom}-,  46 

Ecraseur,  94 

Emiliani,  ovariotomy  by,  66 

Emptying  and  removal  of  cyst,  86 

Enucleation  of  cysts,  92  ;  of  submucous  uterine 

growths,  163 
Epithelioma  of  uterus,  172 
Examination  of  ovaries,  modes  of,  1 
Excision  of  uterus,  171  ;  of  pylorus,  208 
Exploratory  incisions,  121,  141 
Extirpation  of  ovaries,  Blundell  on,  12-5 
Extra-uterine  foetation,  diagnosis  of,  28 


214 


INDEX 


F.iiCAL  uccumulations,  diagnosis  of,  31  ;  case  of, 

mistaken  for  ovarian  tumour,  32;  fistula  after 

ovariotomy,  113 
Fainting  after  ovariotomy,  98 
Fallopian  tuLes,  tumours  of,  168 
Fatty  tumours  of  abdomen,  2-t 
Fehling  on  castration  of  women,  129 
Fibrine  in  abdominal  fluids,  17 
Fibroma-moUuseum,  2.3 
Fibro-plastic  tumoars  of  peritoneum,  omentum, 

&c.  24 
Fistula,  fa?eal,  after  ovariotomy,  113 
Forceps,   79  ;   left  in  abdomen,  99  ;  description 

of  large,  SO 
France,  ovariotomy  in,  63 

Gastrostomy,  207 
Gastrotomy,  208 

Germany,  ovariotomy  in,  64  ;  results  of  myomo- 
tomy  in,  145 

II.TJMATOCELE,  diagnosis  of,  34;  after  ovario- 
tomy, treatment  of,  109 

Hegar  on  extirpation  of  ovaries,  125 

History  of  patients  recovered  after  ovariotomy, 
130 

Hofmeier,  reports  on  myoniotoiny,  145 

Houston,  operation  by,  48 

Hunter,  Dr.  W.,  John,  quotations  from,  40 

Hydatids,  diagnosis,  25 

Hjdrometra,  diagnosis,  treatment  by  tapping  and 
drainage,  29 

Ice  cap,  109 

Incision,  treatment  of  ovarian  cysts  by,  45 ;  in 

ovariotomy,  81  ;  exploratory,  121,  141 
Incomplete  ovariotomy,  121 
Injuries  to  viscera  during  ovariotomy,  98 
Intestinal  obstruction,  209 
Intestines  strangulated  after  ovariotomy,  1 1 1 
Investigation  and  recording  of  cases,  modes  of, 

35 
Iodine,  injection  of,  45 
Italy,  ovariotomy  in,  06 

JuNKKR,  apparatus  for  administering  ana>stlielic.s, 
58 

Keith,  ovariotomy  by,  63 
Kidney,  operative  surgery  of,  190 
Kivvisch,  influence  of  liis  book  and  tables  ap- 
pended by  Clay  of  Birmingham,  53 
Kceberle,  drainage-tubes,  109;  forceps,  79 

Ligatures,  material  for,  50,  60  ;  mode  of  apply- 
ing, 91 ;  experiments  of  Spiegelbcrg  and 
Waldeyer,  93  ;  what  becomes  of  them,  94 


Lister,  his  antiseptic  system  introduced  at 
Samaritan  Hospital,  68 ;  my  experience  of 
his  spray  and  dressings,  63 

Liver  and  gall-bladder,  201 

Mkhu,  conclusions  from  examination  of  ovarian 
fluids,  17 

Mesenteric  cysts,  204 

Methylene,  its  introduction,  77;  my  experience 
of,  77 

Microscope  in  diagnosis,  15 

Mortality  after  ovariotomy,  59;  increase  of 
caused  by  adhesions,  70 ;  at  diiferent  ages, 
71 ;  after  double  ovariotomy,  101  ;  from 
tetanus,  114;  after  exploratory  incisions,  122; 
after  oophorectomy,  129;  after  mj'omotomy, 
145 ;  after  the  Caesarean  and  Porro's  opera- 
tions, 181 

Myomotomy,  indications  for,  144;  early  history 
of,  144;  results  in  Germany,  Ilofmeier's  re- 
ports, 145 

NjiLATOx,  visit  to  England,  his  publication,  in- 
fluence in  France,  63 

Nephrectomy,  19S 

Nephrolithotomy,  201 

Nephroraphy,  190 

Nephrotomy,  197 

Nickel,  on  instruments,  60 

Nicolajsen,  operations  by,  66 

Note-book,  description  of,  35 ;  mode  of  using, 
36 

Nurse,  qualiflcations  for,  74  ;  duties  of,  75 

Nussbaum,  operations  by,  65 

Ob-stkuction,  intestinal,  209 

Olshausen,  operations  by,  65 

Omental  cysts,  204 

Oophorectomy,  suggested  by  Blimdell,  practised 
by  Battey,  125;  Hegar's  suggestions,  125; 
cases  of,  126  ;  caution  respecting,  128  ;  for 
hernia  of  ovaries,  129;  statistics  of,  129; 
operations  by  Savage,  129;  Fehling's  reports 
on,  130  ;  at  Samaritan  Hospital,  130 

Ovariotomy,  early  history  of,  46 ;  opinions  of 
the  Hunters,  47 ;  John  Bell's  lectures  on, 
McDowell's  first  operation,  47  ;  operation  by 
Houston,  48  ;  early  operations  in  Great 
Britain,  60;  my  first  operations,  51;  first 
book  on,  55  ;  operations  in  Samaritan  Hospi- 
tal, 59;  results,  59;  influence  of  antiseptics, 
60  ;  by  Keith,  03  ;  in  France,  63  ;  in  Belgium, 
64;  in  Switzerland,  64;  in  Germany,  64;  in 
North  of  I'hiropo,  65;  in  Italy,  66;  in 
America  antl  Colonics,  67  ;  preparation  of  a 
patient  for,  73 ;  place  for  operation,  74 ; 
qualifications  of  nurse,  74 ;  tables  for,  76  ; 
instruments    necessary    for,    76 ;    operation, 


INDEX 


215 


instructions  for,  80  ;  both  ovaries  removed  at 
one  operation,  100;  twice  on  the  same  patient, 
102  ;  treatment  after,  lOG  ;  fa?cal  fistula  afrcr, 
113;  aceiJents  during  the  operation,  97  ;  dur- 
ing pi'ognancy,  115;  incomplete  ovariotomy, 
121;  results  of.  130;  history  of  patients  re- 
covered from,  130 
Ovary,  absence  of,  1  ;  examination  of,  2 ;  dis- 
placements of,  2  ;  diagnosis  of  different  kinds 
of  tumours  of,  3 ;  solid  tumours  of,  4 ; 
differential  diagnosis  of  tumours  of,  10;  con- 
tents of  normal  follicles  of,  15  ;  position  when 
tumefied,  29;  palliative  treatment  of  tumours 
of,  37 ;  removal  of  by  natives  of  Australia 
and  Now  Zealand,  46;  cancer  of,  72;  examina- 
tion of  second  ovary  diiring  ovariotomy,  95 ; 
removal  of  both  ovaries  at  same  time,  IOC  ; 
reasons  for,  danger  of,  101 ;  results  of,  102; 
return  of  disease  in  second  ovary  after  re- 
moval of  one,  102;  cysts  of,  drainage,  121- ; 
removal  of,  for  fibroid  growths  of  uterus, 
128, 167 

Palliative  treatment  of  ovarian  cases,  37 ; 
tapping  through  abdominal  wall,  39  ;  through 
the  vagina,  44  ;  through  the  rectum,  45 ; 
injection  of  iodine,  45;  by  incision,  45;  of 
uterine  cases,  142;  relief  of  symptoms,  143; 
effect  of  Kreuznach  and  Woodhall  spa  waters, 
143 

Palpation,  in  diagnosis,  14,  138 

Pancreatic  cysts,  205 

Pean,  work  on  ovariotomy  by,  64  ;  work  on  uter- 
ine tumours,  144;  res\ilts  of  his  practice,  145 

Peaslee,  repeated  washings  of  peritoneum,  109 

Pedicle,  structure  of,  7;  rotation  of,  8  ;  absence 
of,  10;  compression  of,  78;  division  of,  79; 
large  forceps  for  holding,  80 ;  treatment  of 
by  clamp,  88  ;  by  ligature,  91  ;  ligatures  for, 
92 ;  division  of  by  ecraseur,  94 ;  by  cautery, 
94 ;  results  of  different  modes  of  treating, 
95  ;  mode  of  dealing  with  in  double  ovario- 
tomy, 102;  adhesions  of  after  ovariotomy,  111; 
intra  and  extra  peritoneal  treatment  of  in 
myomotomy,  163 

Pelvic  cellulitis  and  abscei-s,  33 

Pelvis,  gravitation  of  fluids  or  intestines  into, 
111 

Percussion  in  diagnosis  of  ovarian  tumours,  14  ; 
in  uterine  tumours,  139 

Peritoneum,  cancer  of,  21;  chronic  inflamma- 
tion of,  19  ;  closure  of  wounds  of,  53;  division 
of  in  ovariotomy,  84;  sponging  of,  95;  re- 
peated washings  of  by  Peaslee,  109;  collection 
of  fluids  in,  109;  pouch  of  in  pelvis,  112; 
sewn  over  stump  of  uterine  fibroids,  158 

Peritonitis,  early  opinions  about,  56  ;  its  rehition 
to  septicemia,  61 ;  operative  treatment  of,  211 

Physometra,  diagnosis,  29 


Porro,  liis  operation,  179;  results,  181 
Pregnancy,  differential  diagnosis  of,  26  ;  ovario- 
tomy during,  115;  table  of  cases,  121;  exci- 
sion of  uterus  during,  172;  complication  of 
uterine  tumours  with,  164 
Pylorus,  excision  of,  208 


Removal  of  both  ovaries  at  one  operation,  101 

Penal  cysts,  diagnosis,  30 

Eesidts  of  different  modes  of  treating  pedicle, 
95;  of  ovariotomy,  130;  of  exploratory  inci- 
sions, 122;  of  oophorectomy,  129  ;  of  myomo- 
tomy, 145  ;  of  Porro's  operation,  181 

Peturn  of  disease  after  ovariotomy,  133 

Round  ligament,  tumours  of,  171 

Russia,  ovariotomy  in,  66 


Salicylic  wool,  96 

Samaritan  Hospital,  ovariotomies  done  in,  58  ; 

Battey's  operation,  130 
Savage  on  removal  of  uterine  append  igcs,  129 
Scherer  on  paralbumen,  16 
Schroeder,  operations  by,  65 
Schultze  on  displacements  of  ovaries,  2 
Season  as  affecting  ovariotomy,  71 
Separation  of  cyst  in  ovariotomy,  F,Q 
Septicsemia,  67 

Serous  membranes,  wounds  of,  53 
Silk  for  ligatures  and  sutures,  56,  60 
Size  of  ovarian  tumours,  69 
Social  condition  as  affecting^ovariotomy,  71 
Spiegelberg,  experiments  on  ligatures,  93 
Spleen,  extirpation  of,  182 
Sponges  left  in  abdomen,  necessity  for  counting 

before  and  after  operation,  99 
Sponging  of  peritoneum,  95 
Spray  of  carbolic  acid,  60 
Statistics   of  ovariotomy,  59  ;    of  myomotomy, 

145 
Structui'es  in  abdominal  wall,  82 
Sulphurous  acid  as  a  disinfectant,  00 
Sutures,  material  of,  56,  60 ;  node  of  applying 

96 
Switzerland,  ovariotomy  in,  64 

Tappixg,    38 ;    through   abdominal    wall,    39  : 

through  the  rectum,  44  ;  through  the  vagina, 

44  ;  of  renal  cysts,  192 
Testicle,  undescended,  206 
Tetanus,  114 

Thornton,  case  of  gastrotomy,  208 
Treatment  after  ovariotomy,  106 
Trocar,  78,  86 
Tumours,  uterine,  134;   of  Fallopian  tube,  168; 

of  round  ligament,  171;   of  spleen,  182;  of 

mesentery  and  omentum,  204,  20o 
Tympanites,  22 


210 


INDEX 


UxEEiXE  tumours,  13i;  forms  of,  13o;  size  of, 
135  ;  life  historj-  of,  13G  :  early  operations  for, 
137;  examination  for,  139;  exploratory  inci- 
sions, 141;  medical  treatment,  142;  surgical 
treatment,  144;  classification  of  uterine 
tumours,  144  ;  indications  for  myomotomy, 
141;  early  history  of  myomotomy,  144:  re- 
sults in  Germany,  Hofmeier's  reports,  145; 
subperitoneal  outgi'O'wths,  146 ;  fibro-cj-stic 
outgroAvths,   150;    enucleation  of,  160;   sub- 


mucous ingrowths,  1G3;  complication  of  with 
pregnancy,  164;  removal  of  ovaries  for,  167 
Uterus,  amputation  of,  152;  excision  of,  171 

YiECHow  on  fibroma-molluscum,  24 

"Wards  for  ovariotomy,  74 

Worms,  pamphlet  on  ovariotomy,  63 

Wound,  closure  of,  9a 


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AN/ESTHETICS 
Sansom.  Chloroform.  - 
Turnbull.     2d  Ed. 

Cocaine. 

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Braune.    Topographical. 
Heath.    Practical.    - 
Holden.    Dissections. 

Landmarks.  - 

Handy.    Te.\t-book. 
Morris.     On  the  Joints.  - 
Potter.    Compend  of 

Visceral. 

Wilson.     10th  Ed. 

ATLASES   AND   DIAGRAMS. 
Bentley  and    Trimens.     Medici- 


PAGK 

-     19 


nal  Plants 
Braune.     Of  Anatomy.    - 
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Fox.     Of  Skin  Dis.  -        -     1 

Godlee.     Of  Anatomy.    - 
Hutchinson.     Surgery.  - 
Heath.     Operative  Surgery.         1 
Jones.     Membrana  Tympani. 
Marshall's  Physiol.  Platts.     - 
Schultze.    Obstetrical  Plates. 

BRAIN  AND  INSANITY. 
Bucknill  and  Tuke.     Psycholog 

cal  Medicine.         -         .         . 
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Wood.     Brain  and  Overwork       : 

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Allen.     Commercial  Analysis. 
Hartley.     Medical. 
Bernay.     Notes.       -        -        -     i 
Bloxam's  Te.\t-Book. 

Laboratory. 

Bowman's  Practical. 
Krankland.     How  to  Teach.       i 
Kollmyer.     Key  to.         -        .     ] 
Leffman's  Compend.       -         -     ; 
Muter.     Med'l  and  Pharm.     - 

Practical  and  Analy. 

Richter's  Inorganic.         ■         -     1 

Organic.        -         -         -     : 

Stammer.  Problems.  -  -  : 
Sutton.  Volumetric  Anal.  -  : 
Thompson's  Physics.  -  -  ; 
Tidy.     Text-book.  -         -     ; 

Vacher's  Primer  of.  -        .     ; 

Valentin.  Quant.  Analy.  -  : 
Ward's  Compend  of.  -  -  ; 
Watts.     Phjsical  and  Inorg.  -    ; 

CHILDREN. 
Chavasse.     Mental  Culture  of. 
Day.     Diseases  of.   - 
Dillnberger.     Women  and.    - 
Ellis.     Manual  of  Dis.  of.        -     1 

Mother's  book  on.    -         : 

Goodhart  and  Starr's  New 

Manual  of  Diseases  of.  -         -     ; 
Hale.     Care  of.         -        -         -     ; 
Hillier.     Diseases  of.       -        -     : 
Meig's  and  Pepper'sT realise. 
Smith.     Wasting  Diseases  of. 

COM  PEN  DS 
And  The  Quiz-Competids. 
Brubaker's  Physiology. 
Genois.     Pliarniacy. 
Horwitz.     Surgery. 
Hughes.     Practice.     2  Pts.     - 


13 


19 


PAGE 

Landis.     Obstetrics.        -        -  i^ 

Leffmann's  Chemistry.            -  14 

Potter's  Anatomy.            -         .  18 

Visceral  Anatomy           -  18 

Materia  Medica.      -        -  18 

Ward's  Chemistry.           -        -  22 

Mendenhall's  Vade  Mecum.  16 
Roberts.     Materia  Medica  and 

Pharmacy.       -         -        -        -  19 
DEFORMITIES. 

Churchill.     Face  and  Foot.  8 

Coles.     Of  Mouth.   -        -        -  9 

Prince.     Orthopaedics.     -        -  18 

Reeves.           "                -        -  18 

DENTISTRY. 

Barrett.     Dental  Surg.    -        -  6 

Coles.     Dental  Note  Book.      -  9 

Flagg.     Plastics.      -         -        -  10 

Gorgas.     Dental  Medicine.     -  11 

Harris.   'Principles  and  Prac.  12 

Dictionary  of.       -         -  12 

Heath.     Dis.  of  Jaws.     -         -  12 
Hunter.     Mechanical  Dent. 
Leber    and     Rottenstein. 

Caries.  -----  14 
Richardson.  Mech.  Dent.  -  18 
Sewell.  Dental  Anat.  - 
Stocken.  Materia  Medica.  - 
Tomes.     Dental  Surgery. 

Dental  Anatomy. 

Taft.     Operative  Dentistry.     - 
White.    Mouth  and  Teeth.     - 

DICTIONARIES. 
Cleveland's  Pocket  Medical. 
Cooper's  Surgical.  -        -         - 
Harris'  Dental.         ... 
Longley's  Pronouncing  Med. 

DIRECTORY. 
Medical,  of  Philadelphia, 
Pennsylvania,  Del.  and  South- 
ern N.J.       -         -         .        . 
EAR. 
Burnett.     Hearing,  etc. 
Dalby.     Diseases  of. 
Jones.    Aural  Surgery.     - 

Membrana  Tympani. 

Sight  and  Hearing. 

^Voakes.     Deafness,  etc. 
Catarrh,  etc. 

ELECTRICITY. 
Althaus.     Medical  Electricity. 
Reynolds.    Clinical  Uses. 

EYE. 
Arlt.     Diseases  of.   - 
Carter.     Eyesight.   - 
Daguenet.    Ophthalmoscopy. 
Fenner.     Vision. 
Gowers.     Ophthalmoscopy.  - 
Harlan.     Eyesight. 
Higgins.     Handbook,     - 
Jones.     Sight  and  Hearing.     - 
Macnamara.     Diseases  of.     - 
Morton.     Refraction. 
Wolfe.     Diseases  of. 

FEVERS. 
Welch.     Enteric  Fever.  - 

HEADACHES. 
Day.     Their  Treatment,  etc.  - 
Wright.     Causes  and  Cure.    - 


HEALTH  AND  DOMESTIC 
MEDICINE.  PAGE 


Bulkley.     The  Skin.     ■    - 

7 

Burnett.     Hearing. 

7 

Cohen.     Throat  and  Voice.     - 

8 

Dulles.     Emergencies.    - 

9 

Harlan.     Eyesight. 

12 

Hartshorne.     Our  Homes.     - 

12 

Hufeland.     Long  Life.    - 

13 

Lincoln.     Hygiene. 

14 

Osgood.     Winter.    - 

17 

Packard.      Sea  Air  and   Sea 

Bathing.           .         .         .         . 

17 

Richardson's  Long  Life. 

18 

Tanner.     On  Poisons.      - 

20 

White.     Mouth  and  Teeth.     - 

22 

Wilson.     Summer. 

22 

Wilson's  Domestic  Hygiene. 

'3 

Wood       Brain  Work.      - 

23 

HEART. 

Balfour.     Diseases  of.      - 

5 

Fothergill.     Diseases  of. 

10 

Sansom.     Phjf'l  Diagnosis  of. 

'9 

Diseases  of. 

19 

HEALTH    RESORTS. 

Madden.     Foreign.          -        -  15 

Packard.   Sea  Air  and  Bath'g.  17 

Solly.     Colorado  Springs.        -  19 

Wilson.      The  Ocean  as  a.      -  23 

HISTOLOGY. 

See  Microscope  and  Pathology . 

HOSPITALS. 

Burdett.     Cottage  Hospitals.  7 

Pay  Hospit;ds.      -        -  7 

Domville.     Hospital  Nursing.  9 

HYGIENE. 

Bible  Hygiene,       -        -        -  7 

Frankland.     Water  Analysis.  10 

Fox.     Water,  Air,  Food.          -  10 

Lincoln.     School  Hygiene.     -  14 

Parke's  Hygiene  (Price$3. 00).  17 

Wilson's  Handbook  of.  -        -  23 

•     Domestic.     -        -        -  23 

Naval.           -        -        -  22 

Drainage.     -         -        -  22 

KIDNEY  DISEASES. 
Edwards.     How  to  Live  with 

Briglii's  Disease.    -         -        -  10 

Greenhow.     Addison's  Dis.   -  12 

Ralfe.     Dis.  of  Kidney,  etc.  18 

Tyson.     Brighl's  l>iscase.       -  21 

LIVER. 

Harley.     Diseases  of.      -        -  12 

LUNGS  AND  CHEST. 

jfitjf*  See  Physical  Diagnosis 

and  Throat. 

MARRIAGE. 

Ryan.     Philosophy  of.     -         -  19 

Walker.    For  Beauty,  Health,  22 

MATERIA  MEDICA. 

Biddle.    9th  F.d.      -        -        .  7 

Charteris.     jM.<iuial  of.   -         -  8 

Gorgas.     Denial.     -         -         -  11 

Merrill's  Digest.      -         -         -  16 

Potter's  Coinpcnd  of.       -        -  18 

Roberts'  Compend  of.     -        -  19 

Stocken's  Dental.             -        -  20 


CLASSIFIED  LIST  OF  P.  B  LA  K IS  TON,  SON  &-  CO.'S  PUBLICATIONS. 


MEDICAL  JURISPRUDENCE. 

PAGE 

Abercrombie's  Handbook  of,  5 
Reese's      Text-book     of          -  18 
Woodman  and  Tidy's  Treat- 
ise, iiicliRliii)^  Toxicology.  23 

MICROSCOPE. 

Beale.     How  to  Work  with.    -  6 

In  Medicine.          -         -  6 

Carpenter.     The  Microscope.  8 

Lee.     V'adc  Meciim  of.    -         -  14 
MacDonald.     Examination  of 

W.ilcrby.        -         -         -         -  15 

Martin.     Mounting.         -        -  15 

■Wythe.     The  Microscopist.   -  23 

MISCELLANEOUS. 

Allen.     The  Soft  Palate.          -  6 

Beale.     Life  Theories,  etc.       -  6 

Slight  Ailments.           -  6 

Black.     Micro-Organisms.       -  7 

Cobbold.     Parasites,  etc.          -  8 

Edwards.     Malaiia.        -         -  10 

Vaccination.           -         -  10 

Constipation.        -         -  10 

Gross,     Life  of  Hunter.            -  11 

Hardwicke.    Med.  Educat'n.  12 

Hodge.     Foeticide.            -         -  13 

Holden.    The  Sphygmograph.  13 

Hunter  (John).     Portrait  of.  13 

Kane.     Opiiun  Habit.      -         -  14 

MacMunn.  The  Spectroscope  15 

Mathias.   Legislative  Manual.  16 

Smith.     Ringworm           -        -  '9 

Sieveking.    Life  Insurance.    -  19 

Smythe.     Med'!  Heresies.      -  20 

Wickes.  Sepulture.          -        -  22 

NERVOUS   DISEASES. 
Buzzard.     Ner.  Affections.     -       8 
Flowers.    Atlas  of  Nerves. 
Gowers.    Dis.  of  Spinal  Cord. 

Epilepsy.      -        -        - 

Granville.     Nerve  Vibration. 
Page.     Injuries  of  Spine. 
Radcliffe.   Epilepsy,  Pain, etc. 
Tuke.     Hypnotism,  etc. 
Wilkes.     Nervous  Diseases. 

NURSING. 
Cullingworth.     Manual  of.     - 

— • Monthly    Nursing. 

Domville's  Manual. 
Record  for  the  Sick  Room. 
Temperature  Charts.    - 

OBSTETRICS. 
Cazeaux  and  Tarnier.     New 

Ed.     Colored  Plates.      - 
Gallabin's  Manual  of.     - 
Glisan's  Text-book. 
Larjdis.     Compend. 
Rigby  and  Meadow's. 
Savage.     Female  Pelvic  Org. 
Schultze.     Diagrams. 
Swayne's  Aphorisms 

OSTEOLOGY. 
Holden's  Text-book,     i  Vol. 
Wagstaffe.     Manual  of. 

PATHOLOGY  &  HISTOLOGY 

Gibbes.    Practical    -        -         -  n 

Gilliam.     Essentials  of.  -         -  11 

Jones  and  Sieveking.     -        -  14 

Paget's  Surgical  Path.     -        -  17 

Piersol.     Histology,  40  Plates.  17 

Rindfleisch.     Jeneral.  -  ig 

Virchow.      Post-mortems.     ■  -  21 

Wilkes   and  Moxon.     -        -  22 

PHARMACY. 

Beasley's  Druggists' Receipts.  6 

I  ormidary.      -         -         -  6 

Fliickiger.     Cinchona  Barks.  10 

Genois.     Compend  of.     -        -  11 

Mackenzie.     Phar.  of  Throat,  15 

Merrill's  Di,gest.      -        -         -  16 

Oldberg.     Unofficial  Pharm.  17 

Piesse.     Perfumery.         -         -  17 

Proctor.     Practical  Pharm.    -  18 


13 


PAGE 

Roberts.     Compend  of.            -  19 

Sweringen's  Pharm.  Lex.      -  20 

Tuson.     Veterinary  Pharm.    -  21 

Kirby.     I'harm.  of  Remedies.  14 

POISONS. 

Black.     Formation  of.      -         -  7 

Tanner.     Memoranda  of.         -  20 

Reese.     Toxicology.         -        -  18 

PHYSICAL  DIAGNOSIS 

Barth  and  Roger.           -        -  6 

Bruen's  Handbook.     2d  Ed.  7 

Sansom.    Of  Heart.        -        -  19 

West.     Exam,  of  Chest.          -  22 

PRACTICE. 

Aitken.     2  Vols,     New  Ed.     -  5 

Beale.     Slight  Ailments.           -  6 

Charteris.     Handbook  of.       -  8 

Cormack.     Clinical  Lectures.  y 

Fenwick's  Outlines  of.    -         -  10 

Hughes.     Compend  of.  -         -  14 

Roberts.    I'ext-book.    5th  Ed.  19 

Tanner's  Index  of  Diseases.   -  20 

Warner's  Case  Taking.           -  22 

PHYSIOLOGY. 

Beale's  Bioplasm.    -        -         -  6 

Protoplasm.    -         -         -  6 

Brubaker's  Compend.     -         -  7 

Chapman.     Blood.          -        -  8 

Fulton's  Text-book.        -        -  10 

Kirke's  nth  Ed.       -         -         -  14 

Landois.     Text-book.     -         -  14 

Sanderson's  Laboratory  B'k.  19 

Tyson's  Cell  Doctrine.    -         -  21 

Yeo's  Student's  Manual  -         -  23 

PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.  6 
Receipt  Book.        -         -  6 

Formulary.     -         -         -  6 

Oldberg's  New  Prescriptions.  17 

Pereira's  Pocket-book.             -  17 
■Wythe's  Dose  and  Symptom 

Book.      -         -         -         -        -  17 

RECTUM  AND  ANUS. 

Allingham.    Diseases  of.         -  5 

Cripps.    Diseases  of.         -         -  9 

SKIN  AND  HAIR. 

Bulkley.    The  Skin.         -        -  7 

Cobbold.      Parasites.        ;         -  8 

Fox.     Atlas  of  Skin  Dis.'         -  10 
Van    Harlingen.      Diagnosis 

and  Treatment  of  Skin  Dis.  22 

Wilson.     Skin  and  Hair.         -  23 

STIMULANTS  &  NARCOTICS. 

Anstie.     On,    -        -        -        -  5 

Kane.    Opium  Habit,  etc.        -  14 

Lizars.     On  Tobacco.      -         -  15 

Miller.      On  Alcohol        -        -  16 

Parrish.     Inebriety.         -         -  17 

STOMACH    &   INDIGESTION. 

Allbutt.     Visceral  Neuroses.  15 

Edwards.     Constipation         -  10 

Fenwick.     Atrophy  of.    -         -  10 

Gill.     Indigestion.    -        -        -  11 

SURGERY. 

Cooper's  Dictionary  of.   -        -  8 

Druitt's  Handbook  of.     -         -  9 
Gamgee.     Wounds  and  Frac- 

tiues. II 

Heath's  Operative.           -         -  12 
Minor,    -         -         -         -  12 

Surgical  Diagnosis.        -  12 

Diseases  of  Jaws.          -  12 

Horwitz.     Compend.     2d  Ed.  13 

Hutchinson's  Clinical     -        -  13 

Mears.     Practical.            -        -  16 

Pye,     Surgical  Handicraft.      -  18 

Roberts.     Surgical  Delusions.  19 

■Watson's  Amputations.           -  22 

'TECHNOLOGICAL  BOOKS. 

Sci'  (ilso  Clieinistry. 

Gardner.     Brewing,  etc.         -  11 

Bleaching  and  Dyeing,  n 


Gardner.     Acetic  Acid,  etc.    - 
Overman.     Mineralogy. 
Piggott.     On  Copper. 
Thompson.     Physics.     - 
Piesse.     Perfumery,  etc. 

THROAT  AND  VOICE. 
Cohen.     'Throat  and  Voice.     - 

Inhalations. 

Dobell.     Winter  Cough,  etc.  - 
Greenhow.     Bronchitis. 
Holmes.     Laryngoscope. 
James.     Sore  Throat 


Mackenzie.     'Throat  and  Nose.  15 

Larynx.         -         -         -  15 

Hay  Fever.            -         -  15 

Pharmacopoeia.    -         -  15 

Potter.      Defects  of  Speech.     -  18 

Thorowgood.     ."Vsthma.          -  21 

THERAPEUTICS. 

Cohen.     Inhalations.        -         -  3 

Headland.    Action  of  Med.     -  12 

Kirby.     Phosphorus.        -         -  14 

Selected  Remedies.      -  14 

Mays.     'Therap.  Forces,           -  16 

Ott.     Action  of  Medicines.       -  16 

Potter's  Compend.           -        -  18 

Waring's  Practical.         -         -  22 

TRANSACTIONS    AND 
REPORTS. 

Penna.  Hospital  Reports.  -  37 
Power  and  Holmes'  Reports.  18 
Trans.  College  of  Physicians.  21 
Amer.  Surg.  Assoc.      -  21 

TUMORS  AND  CANCER. 
Hodge.  Note-book  for.  -  13 
Purcell.  Cancer.  -  -  -  18 
Thompson.  Of  the  Bladder.  20 
Wells.  Ovarian  and  Uterine.  22 
Abdominal     -        -        -  22 

URINE  &  URINARY  ORGANS. 

Acton.     Repro.  Organs.           -  3 

Beale.     Urin    and  Renal  Dis.  6 

Urinary  Deposits.         -  6 

Curling.     t)n  the  Testes.         -  9 

Legg.     On  Urine.     -        -         -  14 

Marshall  and  Smith.    Urine.  15 

Thompson.     Urinary  Organs.  20 

Surg,  of  Urin,  Organs,  20 

Calculou.s  Dis.        -         -  20 

Lithotomy.     -         -         -  20 

Prostate.          -         -         -  20 

'Tumors  of  Bladder.       -  20 

Stricture.         -         -         -  20 

Tyson.     Exam,  of  L^rine.        -  21 

VENEREAL  DISEASES. 

Cooper.     Syphilis,  -        -        .  ^ 

Durkee.     Gonorrhoea,      -         -  ,j 

Lewen.     Syphilis,   -         -        -  14 

VISITING  LISTS  AND  AC- 
COUNT BOOKS. 
Lindsay    and     Blakiston's 

Regular  Edition.    -         -         -  17 

Perpetual  Edition.          -  17 

Watson's  Led.  and  Cash  Bk.  22 

VETERINARY  PRACTICE. 

Armatage's  Pocket-book  of.   -  5 

Tuson's  Vet.  Pharmacopoeia.  21 

WATER. 

Fox.     Water,  Air,  Food.          -  lo 

Frankland.     Analysis  of.         -  lo 

MacDonald.        "         "         -  15 

WOMEN,  DISEASES  OF. 

Byford's  Text-book.        -        -  8 

Uterus.  -        -         -         .  8 

Courty.     Uterus,  Ovaries,  etc.  9 

Dillnberger.     Children  and.  9 

Duncan.     Sterility.          -        -  9 

Gallabin.     Diseases  of.   -         -  11 

Savage.     Surgery  of.       -        -  19 

Tilt.     Change  of  Life.      -        -  20 


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included.  By  R.  Bentley,  f.r.s.,  Professor  of  Botany,  King's  Collge,  London, 
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MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  7 

BIBLE  HYGIENE ;  or  Health  Hints.  By  a  physician.  Written  to  impart  in  a 
popular  and  condensed  form  the  elements  of  Hygiene;  showing  how  varied  and 
important  are  the  Health  Hints  contained  in  the  Bible,  and  to  prove  that  the 
secondary  tendency  of  modern  Philosophy  runs  in  a  parallel  direction  with  the 
primary  light  of  the  Bible.     i2mo.  Paper,  .50;  Cloth,  Si-oo 

BIDDLE'S  Materia  Medica.  Ninth  Edition.  For  the  Use  of  Students  and  Physi- 
cians. By  Prop".  John  B.  Biddle,  m.d.,  Professor  of  Materia  Medica  in  Jeffer- 
son Medical  College,  Philadelphia.  The  Ninth  Edition,  thoroughly  revised,  and 
in  many  parts  rewritten,  by  his  son,  Clement  Biddle,  .m.d..  Assistant  Surgeon, 
U.  S.  Navy,  assisted  by  Henry  Morrls,  m.d.  Containing  all  the  additions  and 
changes  made  in  the  last  revision  of  the  United  States  Pharmacopoeia.  The 
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BLACK.  Micro-Organisms.  The  Formation  of  Poisons  by  Micro-Organisms.  A 
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BLOXAM.  Chemistry,  Inorg-anic  and  Organic;  With  Experiments.  By 
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Laboratory  Teaching.  Progressive  Exercises  in  Practical  Chemistry.  In- 
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BOWMAN.  Practical  Chemistry,  including  analysis,  with  about  100  Illustrations. 
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BRATJNE.  Atlas  of  Topographical  Anatomy.  Thirty-four  Full-page  Plates, 
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illustrations.  By  Wilhelm  Braune,  Professor  of  Anatomy  at  Leipzig.  Trans- 
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Physiology  at  Jefferson  Medical  College,  Prof,  of  Physiology,  Penn'a  College  of 
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BRTJEN.  Physical  Diagnosis.  For  Physicians  and  Students.  By  Edward  T. 
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BURDETT'S  Pay  Hospitals  and  Paying  Wards  throughout  the  World.  Facts  in 
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BULKLEY.  The  Skin  in  Health  and  Disease.  By  L.  Duncan  Bulkley,  m.d., 
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BURNETT.  Hearing  and  How  to  Keep  It.  By  Chas.  H.  Burnett,  m.d..  Prof, 
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p.  BLAKISTON,  SON  5-  CO:S 


BTJZZAKD.    Clinical  Lectures  on  Diseases  of  the  Nervous  System.    By  Thos. 

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BYFORD.     Diseases   of   Women      The   Practice   of    Medicine   and    Surgery,    as 

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CARTER.  Eyesig'ht,  Good  and  Bad.  A  Treatise  on  the  Exercise  and  Preservation 
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CAZEAUX  and  TARNIER'S  Midwifery.  Seventh  Revised  and  Enlarged  Edition. 
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Paris.  A  New  American,  from  the  Eighth  French  and  First  Italian  Edition. 
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CHAPMAN.  The  Circulation  of  the  Blood.  A  History  of  the  Discovery  of  the 
Circulation  of  the  Blood.  By  Henry  C.  Chapman,  m.d..  Professor  of  Institutes 
of  Medicine  and  Medical  Juri.sprudence  in  Jefferson  Medical  College,  Phila- 
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CHARTERIS.    The  Practice  of  Medicine.    A  Handbook.    By  M.  Charteris. 

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CHURCHILL.     Face  and  Foot  Deformities.     By  Fred.    Churchill,    m.d.. 

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CLEVELAND'S  Pocket  Dictionary.  A  Pronouncing  Medical  Lexicon,  containing 
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COHEN  on  Inhalation,  its  Therapeutics  and  Practice,  including  a  Description  of 
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trations.    A  New  Enlarged  Edition.     i2mo.  Paper,  .75;  Cloth,  ^i. 25 

The  Throat  and  Voice.    Illustrated.     i2mo.  Cloth,  .50 

COOPER'S  Surgical  Dictionary.  A  Dictionary  of  Practical  Surgery  and  Encyclo- 
paedia of  Surgical  Science.  By  Samuel  Cooper.  New  Edition.  By  Samuel 
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MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  9 


COLES.  Deformities  of  the  Mouth,  Congenital  and  Acquired,  with  Their  Me- 
chanical Treatment.  By  Oaklicy  Coles,  M.D.,  D.D.s.  Third  Edition.  83  Wood 
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The  Dental  Student's  Note-Book.    A  new  Edition.     i6mo.  Cloth,  $1.00 

COOPER  on  Syphilis  and  Pseudo-Syphilis.  By  Alfred  Cooper,  f.r.c.s.,  Sur- 
geon to  the  Lock  Hospital,  to  St.  Marks,  and  to  the  West  London  Hospitals. 
Octavo.  Cloth,  $3.50 

CORMACK'S  Clinical  Studies.  Illustrated  by  Cases  observed  in  Hospital  and 
Private  Practice.  By  Sir  John  Rose  Cormack,  m.  d.,  k.  b.,  etc.  Illustrated. 
2  vols.  1 1 27  pp.  Cloth,  $5.00 

COXJRTY.  The  Uterus,  Ovaries,  etc.  A  Practical  Treatise  on  Diseases  of  the  Uterus, 
Ovaries  and  Fallopian  Tubes.  By  Prof.  A.  Courty,  of  Montpellier,  France. 
Translated  from  the  Third  Edition,  by  his  pupil  and  assistant,  Agnes  McLaren, 
M.D.,  M.K.Q. C.P.I.  With  a  Preface  by  J.  Mathews  Duncan,  m.d.,  ll.d.,  f.r.s., 
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CRIPPS.  Diseases  of  the  Rectum  and  Anus,  including  a  portion  of  the  Jackson- 
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CULLINGWORTH.  A  Manual  of  Nursing-,  Medical  and  Surgical.  By  Charles 
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A  Manual  for  Monthly  Nurses.    32mo.  Cloth,  .50 

CURLING.    On  the  Diseases  of  the  Testis,  Spermatic  Cord  and  Scrotum.    By 

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DAGUENET'S   Ophthalmoscopy.     A    Manual  for  the  Use  of  Students.     By  Dr. 

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DALBY.  The  Ear.  The  Diseases  and  Injuries  of  the  Ear.  By  W.  B.  Dalby,  m.d., 
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much  Enlarged.     Svo.     752  pp.     Price  reduced.  Cloth,  $3.00;  Sheep,  $4.00 

On  Headaches.     The  Nature,  Causes  and  Treatment  of  Headaches.     Fourth 

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DILLNBERGER.  On  Women  and  Children.  A  Handbook  of  the  Treatment 
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DOBELL.  On  Winter  Cough,  Catarrh,  Bronchitis,  Emphysema,  Asthma,  etc.  By 
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DOMVILLE.  Manual  for  Nurses  and  others  engaged  in  attending  to  the  sick. 
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DRUITT'S  Modern  Surgery.  The  Surgeon's  Vade  Mecum  ;  a  Manual  of  Modern 
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DULLES.  What  to  Do  First,  In  Accidents  and  Poisoning.  By  C.  W.  Dulles,  m.d. 
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DUNCAN,  On  Sterility  in  Women.  By  J.  Mathews  Duncan,  m.d.,  ll.d..  Obstetric 
Physician  to  St.  Bartholomew's  Hospital,  etc.     Octavo.  Cloth,  i^2.oo. 

DURKEE,  On  Gonorrhoea  and  Syphilis.    By  Silas  Durkee,  m.d.    Sixth  Edition. 
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B 


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FENWICK'S  Outlines  of  Practice  of  Medicine.    With   Appropriate    Formulas 
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FLAGG'S  Plastics  and  Plastic  Filling;  As  Pertaining  to  the  Filling  of  all  Cavities 
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Illustrations.  By  J.  Foster  Flagg,  d.d.s..  Professor  of  Dental  Pathology  and 
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the  Cutaneous  Surface,  and  to  all  the  Muscles.  By  William  H.  Flower, 
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FLUCKIGER.  The  Cinchona  Barks  Pharmacognostically  Considered.  By 
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Hospital,  Birmingham.     34  Engravings.     Second  Edition.     8vo.        Cloth,  $3,50 

GARDNER'S  TECHNOLOGICAL  SERIES.    The  Brewer,  DistiUer  and  Wine 

Manufacturer.     A  Handbook  for  all  Interested  in  the  Manufacture  and  Trade 
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vised and  Improved,  Illustrating  the  Whole  Human  Body. 

The  Set,  1 1  Maps,  in  Sheets,  $50.00 

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16  P.  BLAKISTON,  SON  <S^  CO:S 

MARTIN'S  Microscopic  Mounting.  A  Manual.  With  Notes  on  the  Collection 
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Philadelphia,  etc.,  etc.,  and  William  Pepper,  m.d..  Physician  to  the  Philadel- 
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MERRELL'S  Digest  of  Materia  Medica.  Forming  a  Complete  Pharmacopoeia  for 
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18  P.  BLAKISTON,  SON  <S-  CO.'S 

POTTER.  Speech  and  Its  Defects.  Considered  Physiologically,  Pathologically 
and  Remedially ;  being  the  Lea  Prize  Thesis  of  Jefiferson  Medical  College,  1882. 
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Compend  of  Anatomy.     63  Illustrations.     Third  Edition,  Revised. 
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POWER,  HOLMES,  ANSTIE  and  BARNES  (Drs.)  Reports  on  the  Progress  of 
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PRINCE'S  Plastic  and  Orthopedic  Surgery.  By  David  Prince,  m.d.  Contain- 
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PROCTER'S  Practical  Pharmacy.  Lectures  on  Practical  Pharmacy.  With  43 
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PURCELL  on  Cancer  ;  its  Allies  and  other  Tumors ;  with  Special  Reference  to  their 
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208  Illustrations.  Cloth,  $5.00 

RADCIIFFE  on  Epilepsy,  Pain,  Paralysis,  and  other  Disorders  of  the  Nervous 
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RALFE.  Diseases  of  the  Kidney  and  Morbid  Conditions  of  the  Urine  Dependent 
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REEVES.  Bodily  Deformities  and  their  Treatment.  A  Handbook  of  Practical 
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REYNOLDS.  Electricity.  Lectures  on  the  Clinical  Uses  of  Electricity.  By  J. 
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trations.    8vo.  Cloth,  $4.00;  Leather,  $4.75 

RIGBY'S  Obstetric  Memoranda.  Fourth  Edition,  Revised.  By  Alfred  Meadows, 
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RICHTER'S  Inorganic  Chemistry.  A  Text-book  for  Students.  By  Prof.  Victor 
VON  KiciiTEK,  University  of  Breslau.  Authorized  Translation  from  the  Third 
German  Edition,  by  Edgar  F.  Smith,  m.a.,  ph.d.,  Prof,  of  Chemistry,  Witten- 
berg College,  formerly  in  the  Laboratories  of  the  University  of  Pennsylvania, 
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RINDFLEISCH'S  General  Pathology.  A  Handbook  for  Students  and  Physicians. 
By  Prof.  Edward  Rindfleisch,  of  Wurzburg.  Translated  by  Wm.  H.  Mercur, 
M.D.,  of  Pittsburgh,  Pa.,  Edited  and  Revised  by  JAiMes  Tyson,  m.d.,  Professor  of 
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ROBERTS.  Practice  of  Medicine.  Fifth  Edition.  The  Theory  and  Practice  of 
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SANSOM'S  Physical  Diagnosis  of  Diseases  of  the  Heart.     Including  the  Use  of 

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Valvular  Disease  of  the  Heart.     Illustrated.     i2mo.  Cloth,  $1.25 

On  Chloroform.     Its  Action  and  Administration.         Paper,  .75  ;  Cloth,  ;?i. 25 

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Anatomy  of  the  Female  Pelvic  Organs.  In  a  Series  of  Colored  Plates  taken 
from  Nature,  with  Commentaries,  Notes  and  Cases.  By  Henry  Savage,  m.d., 
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SCHULTZE'S  Obstetrical  Plates.  Obstetrical  Diagrams.  Life  Size.  By  Prof.  B. 
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SEWELL'S  Dental  Surgery.  A  Manual  of  Dental  Anatomy  and  Surgery, 
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SOLLY'S  Colorado  Springs  and  Manitou  as  Health  Resorts.  By  S.  Edwin  Solly, 
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of  the  State.     i2mo.  Paper  cover,  .25 

SMITH  on  Ringworm.  Its  Diagnosis  and  Treatment.  By  Alder  Smith,  f.r.c.s. 
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SMITH'S  Wasting  Diseases  of  Infants  and  Children.  By  Eustace  Smith,  .m.d., 
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Edition,  Enlarged.     8vo.  Cloth,  $3.00 


20  P.  BLAKISTON,  SON  <&-  CO:S 

SMYTHE'S  Medical  Heresies.  Historically  Considered.  A  Series  of  Critical  Es- 
says on  the  Origin  and  Evolution  of  Sectarian  Medicine,  embracing  a  Special 
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Also,  LECTURES  ON  SOME  IMPORTANT  POINTS  connected  with  the 
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DUNCAN  ON  STERILITY  IN  WOMEN.  Being  the  Gul.stonian  Lectures  for  1883. 
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M.D.     Svo.  Cloth,  $2.00 

WOAKES  ON  CATARRH  AND  DISEASES  OF  THE  NOSE  CAUSING 
DEAFNESS.  By  EinvARD  \Vo.\kes,  m.d.,  Senior  .\ural  Surgeon  to  the  London  Hos- 
pital for  Diseases  of  the  Throat  and  Chest.     29  Illustrations,      uino.  Cloth,  $1.50 

WARNER.  CLINICAL  MEDICINE  AND  CASE  TAKING.  By  Francis 
Warner,  M.D. ,  F.R.C.P.     2d  Edition.     i2mo.  Cloth,  $1.75 

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The  Physician's  Visiting  List. 

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Published  Annually;  now  in  its  Thirty-fourth  Year. 

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Method  in  Asphyxia,  Lists  of  New  Remedies,  Sylvester's  Method  for  Producing 
Artificial  Respiration,  with  Illustrations ;  Diagram  for  Diagnosing  Diseases  of 
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The  Qitality  of  the  Lealher  used  in  Biiiiiiiig  litis  List  has  been  again  Impi-oved,  and  a 
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Medical  News. 

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The  Practical  Series. 

A  SET   OF    COMPACT    HANDBOOKS    FOR   THE 
PHYSICIAN  AND  STUDENT, 


Under  this  title  it  is  proposed  to  issue  a  series  of  compact,  practical  books  on  the 
various  branches  of  Medicine,  Surgery  and  Gynaecology.  The  volumes  will  be  pre- 
pared by  authors  of  known  capability,  who  have  made  special  studies  of  the  subjects 
upon  which  they  write.  It  will  be  the  special  aim  of  each  writer  to  give  the  latest 
information  in  the  most  concise  manner  consistent  with  usefulness  and  practicability. 
The  three  great  questions  of  Diagnosis,  Prognosis  and  Treatment  will  be 
especially  borne  in  mind  and  worked  out  to  the  best  advantage,  so  that  the  most 
important  points  may  be  caught  at  once  by  the  reader. 

NOW  READY.     Handsomely  Bound  in  Red  Cloth. 

BODILY  DEFORMITIES  AND  THEIR  TREATMENT.  A  Handbook  of 
Practical  Orthopaedics.  By  H.  A.  Reeves,  f.r.c.s..  Senior  Assistant  Surgeon 
and  Teacher  of  Practical  Surgery  at  the  London  Hospital ;  Surgeon  to  the  Royal 
Orthopaedic  Hospital,  etc.     i2mo.     228  Illustrations.     460 pages.     Cloth.     $2.25. 

"  From  what  we  have  already  said,  it  will  be  seen  that  Mr.  Reeves  has  given  us  a  trustworthy  guide  for  the 
treatment  of  a  very  extended  class  of  cases.  *  *  *  *  If  the  other  volumes  of  the  Practical  Series  are  as  good 
as  this,  we  shall  be  agreeably  disappointed." — American  Journai  of  Medical  Sciences,  April,  i88S- 

"  Within  llie  compass  of  450  pages  this  well-known  surgeon  has  managed  to  compress  an  amount  of  practical 
information  concerning  orthopaedics  that  is  truly  astonishing.  *  *  *  *  The  whole  subject  of  orthopasdics  is 
treated  from  the  standpoint  of  the  general  as  well  as  the  orthopaedic  surgeon,  which,  in  our  eyes,  is  one  of  the 
chief  recommendations  of  the  book.  The  judicial  fairness  which  marks  the  consideration  of  differing  plans  of 
treatment,  and  the  distinct  enunciation  that  indications  alone  must  be  considered,  and  that  any  apparatus  must 
be  used  which  will  best  carry  these  out  and  lukich  is  available  to  the  practitioner  or  patient  in  each  individual 
case,  is  another  remarkable  feature  of  the  book.  *  *  *  *  \Ve  have  rarely  been  so  much  pleased  with  any 
book,  and  it  is  one  which  we  shall  recommend  as  a  text-book  to  our  classes." — The  Polyclinic. 

"The  utility  of  the  work  now  before  us  cannot  be  better  recommended  to  the  appreciation  of  the  professional 
reading  public,  than  by  recalling  that  it  is  the  first  of  its  kind  dealing  with  orthopaedics  from  a  modern  stand- 
point."— Hospital  Gazette  and  Students    yournal. 

DENTAL  SURGERY  FOR  GENERAL  PRACTITIONERS  AND  STUDENTS 

OF  MEDICINE.  By  Ashlev  W.  Barrett,  m.d.,  m.r.c.s.,  Eng.,  Surgeon- 
Dentist  to,  and  Lecturer  on  Dental  Surgery  and  Pathology  in  the  Medical 
School  of,  London  Hospital.     i2mo.     Illustrated.  Cloth.     #i.oo. 

"  Replete  with  an  abundance  of  practical  information  of  unquestionable  utility." — Hospital  Gazette  and 
Students'  yournal. 

DISEASES  OF  THE  KIDNEY,  AND  MORBID  CONDITIONS  OF  THE 
URINE,  Dependent  on  Functional  Derangements.  By  C.  H.  Ralfe,  m.a.,  m.d., 
F.R.C.P.,  Assistant  Physician  to  the  London  Hospital ;  late  Senior  Physician  to 
the  Seamen's  Hospital,  Greenwich.     i2mo.     With  Illustrations.     Nearly  Ready. 

Other  volumes  in  preparatio7i,  and  will  be  announced  shortly. 
P.  BLAKISTON,  SON  &  CO.,  Medical  Publishers  and  Booksellers, 

1012  WALNUT  ST.,  PHILADELPHIA. 


?  OUIZ-COMPENDS  ? 

A  NEW  SERIES  OP  PRACTICAL  MANUALS  FOE  THE   PHYSICIAN  AND  STUDENT. 

Compiled  in  accordance  with  the  latest  teachings  of  prominent  lecturers 
and  the  most  popular  Text-books. 

They  form  a  most  complete  set  of  Compends,  containing  information  nowhere  else  collected 
in  such  a  condensed,  practical  shape.  The  authors  have  had  large  experience  as  quiz  masters 
and  attaches  of  colleges,  with  exceptional  opportunities  for  noting  the  most  recent  advances  in 
therapeutics,  methods  of  treatment,  etc.  The  arrangement  of  the  subjects,  illustrations  and 
types,  are  all  of  the  most  improved  form,  and  the  size  of  the  books  is  such  that  they  may  be 
easily  carried  in  the  pocket. 

Bound  in  Cloth,  each  $i.oo.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 


No.  I.  Human  Anatomy.  Third  Edi- 
tion. Illustrated.  By  Samuel  O.  L. 
Potter,  m.a.,  m  d.,  late  A.  A.  Surgeon  U. 
S.  Army.     With  63  Illus.     3d  Revised  Ed. 

"To  those  desiring  to  post  themselves  hurriedly  for 
examination,  this  little  book  will  be  useful  in  refreshing 
the  memory." — Neiu  Orleans  Med.  and  Surg.  Jl. 

Nos.   2    and    3.     Practice    of    Medicine. 

Especially  adapted  to  the  use  of  Students 
and  Physicians.  By  Daniel  E.  Hughes, 
M.D.,  Demonstrator  of  Clinical  Medicine  in 
Jefferson  Med.  College,  Phila.     In  two  parts. 

Part  I. — Continued,  Eruptive  and  Periodical  Fev- 
ers, Diseases  of  the  Stomach,  Intestines,  Peritoneum, 
Biliary  Passages,  Liver,  Kidneys,  etc.  (including Tests 
for  Urine),  General  Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System  (in- 
cluding Physical  Diagnosis),  Circulatory  System  and 
Nervous  System  ;   Diseases  of  the  Blood,  etc. 

***  These  little  books  can  be  regarded  as  a  full  set  of 
notes  upon  the  Practice  of  Medicine,  containing  the 
Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis, 
Diagnosis,  Treatment,  etc.,  of  each  disease,  and  includ- 
ing a  number  of  prescriptions  hitherto  luipublished. 

No.  4.  Physiology,  including  Embry- 
ology. Second  Edition.  By  Albert  P. 
Brup,aker,m.d.,  Prof,  of  Physiology,  Penn'a 
College  of  Dental  Surgery;  Demonstrator 
of  Physiology  in  Jefferson  Med.  College, 
Phila.  Revised  and  Enlarged. 
"  This  is  a  well  written  little  book." — London  Lancet. 

No.  5.  Obstetrics.  Illustrated.  Second 
Edition.  For  Physicians  and  Students. 
By  Henry  G.  Landis,  m.d..  Prof,  of  Ob- 
stetrics and  Diseases  of  Women,  in  Starling 
Medical  Collage,  Columbus.  Revised  Ed. 
New  Illustrations. 

"  We  have  no  doubt  that  many  students  will  find  in 
it  a  most  valuable  aid." —  The  Amer.Jl  of  Obstetrics. 

No.  6.  Materia  Medica  and  Therapeu- 
tics. Second  Revised  Edition.  With 
especial  Reference  to  the  Physiological  Ac- 
tions of  Drugs.  For  the  use  of  Medical, 
Dental  and  Pharmaceutical  Students,  and 
Practitioners.  Based  on  the  New  Revision 
(Sixth)  of  the  U.  S.  Pharmacopoeia,  and 
including   many  unofificinal  remedies.     By 


Samuel  O.  L.  Potter,  m.a.,  m.d.,  late  A. 
A.  Surg.  U.  S.  Army.  Revised  Edition, 
with  Index. 

"  One  of  the  very  best  we  have  ever  seen." — Southern 
Clinic. 

No.  7.  Inorganic  Chemistry.  New  Edi- 
tion. By  G.  Mason  Ward,  m.d..  Demon- 
strator of  Chemistry  in  Jefferson  Med.  Col- 
lege, Phila.  Including  Table  of  Elements 
and  various  Analytical  Tables.     New  Ed. 

"  This  neat  pocket  volume  is  a  brief  but  excellent 
compend  of  inorganic  chemistry  and  simple  analysis  of 
the  metals." — Pharmaceutical  Record,  xV.  i'. 

No.   8.     Visceral  Anatomy.     Illustrated. 

By  Samuel  O.  L.  Potter,  m.a.,  m.d.,  laie 
A.  A.  Surg.  U.  S.  Army.     With  40  Illus. 

"  Worthy  our  recommendation  to  students,  and  a 
ready  reference  to  the  busy  practitioner." — Chicago 
Med.  Times. 

No.  9.  Surgery.  Second  Edition.  Illus- 
trated. Including  Fractures,  Wounds, 
Dislocations,  Sprains,  Amputations  and  other 
operations;  Inflammation,  Suppuration,  Ul- 
cers, Syphilis,  Tumors,  Shock,  etc.  Dis- 
eases of  the  Spine,  Ear,  Eye,  Bladder,  Tes- 
ticles, Anus,  and  other  Surgical  Diseases. 
By  Orville  Horwitz,  a.m.,  m.d.,  Resident 
Physician  Pennsylvania  Hospital,  Phil'a. 
Second  Edition,  Revised  and  Enlarged. 
With  62  Illustrations. 

"Will  prove  very  useful,  both  to  the  student  and 
practitioner." — Valentine  Mott,  m.d.,  Ass' t  to  the 
Prof,  of  Surgery,  Belleviie  Hospital,  Keiu  York. 

No.  10.  Organic  Chemistry.  Including 
Medical  Chemistry,  Urine  Analysis,  and  the 
Analysis  of  Water  and  Food,  etc.  By  Henrv 
Leffmann,  m.d.,  Demonstrator  of  Chemis- 
try in  Jefferson  Med.  College;  Prof,  of 
Chemistry  in  Penn'a  College  of  Dental 
Surgery,  Philadelphia. 

"  It  is  a  useful  and  valuable  addition  to  the  series  of 
Quiz-Compends," — College  and  Clinical  Record. 

No.  II.  Pharmacy.  By  Louis  Genois, 
PH.G.,  Member  of  the  Amer.  Pharmaceutical 
Association.  In  Preparation. 


Bound  in  Cloth,  each  $1.00.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

P.  BLAKISTON,  SON  &  CO., 

MBDIOAL.  BOOKSELLERS  AND  PUBLISHERS,  PHILADELPHIA. 


STANDARD 

Medical  Text-Books. 


HOLDEN'S  ANATOMY.     Fifth  Edition.     Just  Ready. 

A  Manual  of  the  Dissections  of  the  Human  Body.  By  Luther  Holden,m.d.,f.r.c.s., 
Consulting  Surgeon  to  St.  Bartholomew's  and  the  Foundling  Hospitals,  London, 
assisted  by  John  L.angton,  f.r.c.s..  Surgeon  to  and  Lecturer  on  Anatomy  in  St. 
Bartholomew's  Hospital.  Fifth  Edition.  Revised  and  Enlarged,  with  208  Illus- 
trations, many  of  them  new.     Octavo.     One  Handsome  Volume. 

Cloth,  ^5.00;  Leather,  $6.00 

"  Hotden's  works  have  always  been  favorite  text-books  with  medical  students,  and  this  is  largely  due  to  the 
fact  that  they  are  more  easily  read  and  understood  than  any  similar  works  in  the  English,  or  indeed  in  any  foreign 
language.  Dr.  Holdcn  writes  simply  and  clearly,  because  he  has  a  definite  and  precise  idea  of  what  he  intends 
to  write  ;  and  the  student  understands  him  fully,  because  every  statement  is  definitely  and  clearly  put.  There  is 
not  an  involved  sentence,  or  one  capable  of  being  misunderstood,  in  any  of  his  writings.  *  *  *  '|'he  new  edi- 
tion has  been  entirely  revised  by  Mr.  Langton.is  enlarged  by  about  200  pages, and  contains  thirty  new  wood-cuts. 
*  *  *  The  publishers  are  to  be  congratulated  on  the  appearance  of  the  book  :  in  binding,  clearness  of  type,  and 
well  defined  illustrations,  it  leaves  little  or  no  room  for  improvement." — London  Lancet. 

ROBERT'S   PRACTICE.     Fifth  American  Edition^ 

A  Handbook  of  the  Theory  and  Practice  of  Medicine.  By  Frederick  T.  Roberts, 
M.D.,  B.Sc,  F.R.C.P.,  Professor  of  Materia  Medica  and  Therapeutics,  and  of  Clini- 
cal Medicine,  at  University  College;  Physician  to  University  College  Hospital 
and  to  Brompton  Hospital  for  Consumption  and  Diseases  of  the  Chest;  Examiner 
in  Medicine  at  the  Royal  College  of  Surgeons.  The  Fifth  (American)  Revised 
Edition.     8vo.     Illustrated.  Cloth,  $5.00;  Leather,  $6.00 

*^*  The  whole  work  has  been  subjected  to  careful  and  thorough  revision  by  the 
Author,  many  chapters  having  been  entirely  rewritten,  while  important  alterations 
and  additions  have  been  made  throughout.  Several  new  illustrations  have  also  been 
introduced.  It  is  recommended  as  a  text-book  at  the  University  of  Pennsylvania, 
Yale  and  Dartmouth  Colleges,  University  of  Michigan,  and  many  other  Medical 
Schools. 

BIDDLE'S  MATERIA  MEDICA.     Ninth  Edition. 

Materia  Medica.  For  the  Use  of  Students  and  Physicians.  By  Prof.  John  B. 
BiDULE,  M.D.,  Professor  of  Materia  Medica  in  Jefferson  Medical  College.  The 
Ninth  Edition,  thoroughly  revised,  and  in  many  parts  rewritten,  by  his  son, 
Clement  Biddle,  m.d..  Assistant  Surgeon  U.  S.  Navy,  assisted  by  Henry 
Morris,  m.d.,  one  of  the  Demonstrators  in  the  Jefferson  Medical  College.     8vo. 

Cloth,  34.00;  Leather,  $4.75 

"  Nothing  has  escaped  the  writer's  scan.  All  the  new  remedies  against  disease  are  duly  and  judiciously  noted. 
Students  will  certainly  appreciate  its  shapely  form,  grace  of  manner,  and  general  muitutii  in  parvo  style." — 
American  Practitioney. 

MEIGS  AND  PEPPER  ON  CHILDREN.     Seventh  Edition. 

A  Practical  Treatise  on  the  Diseases  of  Children.  By  J.  Forsyth  Meigs,  m.d.,  one 
of  the  Physicians  to  the  Pennsylvania  Hospital;  Consulting  Physician  to  the 
Children's  Hospital,  etc.,  and  William  Pepper,  m.d.,  Professor  of  the  Practice 
of  Medicine,  University  of  Pennsylvania,  and  Provost  and  ex-officio  President 
of  the  Faculty;  Physician  to  the  Philadelphia  Hospital.  The  Seventh  Revised 
and  Improved  Edition.     8vo.  Cloth,  s;6.oo;  Leather,  $7.00 

"  But  as  a  scientific  guide  in  the  diagnosis  and  treatment  of  the  diseases  of  children,  we  do  not  hesitate  to  say 
that  we  have  »cld<.m  met  with  a  tcxt-bf.ok  so  comnlctc,  so  just,  and  so  readable,  as  the  one  before  us.  which  in  its 
new  form  c.-mnoi  fail  to  make  friends  wherever  it  shall  go,  and  wherever  great  erudition,  practical  t.ict,  and  fluent 
and  agreeable  diction  are  appreciated,"— ./^wirr/VaM  Journal  of  Obstetrics. 

P.  BLAKISTON,  SON  &  CO.,  Medical  Publishers  and  Booksellers, 
1012  "WALNUT  STREET,  PHILADELPHIA. 


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